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Difficulty: MediumMental Health Concepts

A client diagnosed with major depressive disorder with psychotic features becomes severely agitated, demands to leave the inpatient psychiatric unit immediately, and stands blocking the main exit door. Which actions should the practical nurse (PN) take? Select all that apply.

  1. Maintain a distance of at least two arm lengths from the client.Answer
  2. Direct other clients in the surrounding area to move to their rooms.Answer
  3. C
    Ask the client, "Why do you feel the need to leave the unit immediately?"
  4. D
    Attempt to logically explain the facility's policy regarding discharges against medical advice.
  5. E
    Assign an unlicensed assistive personnel (UAP) to evaluate the client for signs of escalating aggression.
  6. Request immediate assistance from the charge nurse and other staff members.Answer

Answer

The practical nurse should prioritize safety by maintaining a safe distance from the client, directing other clients away from the area to their rooms, and requesting immediate assistance from the charge nurse and additional staff.
When a client is in an active behavioral crisis, the absolute priority is the safety of the client, staff, and other individuals on the unit. The nurse must maintain physical distance to prevent potential injury, clear the area of other clients to reduce environmental stimulation and protect them, and summon additional help to manage the situation safely and effectively.

Step-by-Step Solution

1
Identify the immediate clinical priority.
Recognize that the client is in an active behavioral crisis and poses a potential safety risk to themselves, staff, and peers.
According to Maslow's hierarchy of needs and psychiatric nursing principles, physical safety of the milieu always takes precedence over psychosocial exploration.
2
Select interventions that ensure safety and fall within the PN scope of practice.
Maintaining physical distance, clearing the area of bystanders, and calling for backup are chosen as safe and appropriate actions.
These actions do not require advanced psychiatric evaluation and immediately help secure the environment without provoking the client.
3
Eliminate inappropriate or unsafe actions.
Asking "why", explaining policies logically, and delegating assessment tasks are eliminated.
These actions either worsen the crisis through nontherapeutic communication, bypass immediate safety needs, or violate the nursing scope of practice regarding delegation.

Key Concept

Crisis Intervention and Milieu Safety
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Topics

Mental Health Concepts

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