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Difficulty: MediumCrisis Intervention

A licensed practical nurse (PN) is working in an acute psychiatric unit. A client with a history of bipolar disorder suddenly begins pacing the hallway, clenching their fists, and loudly demanding to leave the facility immediately. The client's face is flushed, and their breathing is rapid. Which of the following is the most appropriate initial action for the PN to take?

  1. Maintain a safe distance, ensure a clear path to the exit, and speak to the client in a calm, non-threatening voice.Answer
  2. B
    Attempt to logically explain the facility's discharge policies and why the client cannot leave.
  3. C
    Tell the client that everything is going to be fine and there is no reason to be upset.
  4. D
    Immediately obtain physical restraints to ensure the safety of the staff and other clients on the unit.

Answer

Maintain a safe distance, ensure a clear path to the exit, and speak to the client in a calm, non-threatening voice.
When a client exhibits signs of escalating agitation and potential violence, the nurse's first priority is safety. Maintaining a safe distance and ensuring a clear exit path protects the nurse, while using a calm, clear voice is the first step in verbal de-escalation, which is the least restrictive intervention.

Step-by-Step Solution

1
Assess the client's behavioral cues.
The client is pacing, clenching fists, and speaking loudly.
These are clear non-verbal and verbal signs of escalating agitation and a potential behavioral crisis.
2
Determine the priority of care.
Immediate physical safety for the nurse, the client, and others is the top priority.
In a crisis intervention, safety must be secured before attempting any other therapeutic interventions.
3
Select the most appropriate initial intervention.
Maintain a safe distance and use calm verbal de-escalation techniques.
This approach minimizes the threat to the nurse while attempting to reduce the client's escalating anxiety in the least restrictive manner.

Key Concept

Prioritizing physical safety and employing verbal de-escalation techniques during the initial phase of a behavioral crisis.
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Topics

Crisis Intervention

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