While monitoring the dayroom at a behavioral health center, the practical nurse observes a client with acute mania suddenly stand up, knock over a chair, and begin shouting angrily at another individual. Arrange the following nursing actions in the correct order of priority, from first to last.
- 1Direct the other clients in the dayroom to move to a safe, supervised area.
- 2Stand at a safe distance and speak to the agitated client using a calm, clear, and non-confrontational tone.
- 3Offer the client the choice to move to a quiet environment or take an 'as needed' (PRN) medication.
- 4Notify the charge nurse of the escalating situation to prepare for additional intervention.
- 5Document the objective details of the client's behavior and the specific interventions utilized.
Answer
The correct sequence prioritizes immediate milieu safety, followed by least-restrictive verbal de-escalation, offering safe alternatives, escalating to the RN, and finally documentation.
In psychiatric nursing, safety of the milieu is the paramount priority. The practical nurse must first clear the area of potential victims. Once others are safe, the nurse follows the principle of least restrictive intervention. This begins with maintaining physical distance and attempting verbal de-escalation. If the client remains agitated, offering choices such as a quiet room or PRN medication provides a slightly more restrictive, yet still voluntary, option. If these independent and collaborative PN actions fail to calm the client, notifying the charge nurse is required to mobilize a response team. Finally, objective documentation is completed after the crisis is managed.
Step-by-Step Solution
Key Concept
Crisis De-escalation Priority and Least Restrictive Interventions