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Difficulty: MediumMental Health Concepts

A client with a history of a mood disorder is receiving care on a medical-surgical unit. The client begins pacing the hallway rapidly, speaking in a loud, demanding tone, and clenching their fists. Which actions should the practical nurse (PN) take? (Select all that apply.)

  1. Direct other clients and visitors to leave the immediate area.Answer
  2. Maintain a personal distance of at least two arm lengths from the client.Answer
  3. C
    Ask the client, "Why are you becoming so angry and aggressive today?"
  4. Communicate using a calm, low-pitched voice and concise sentences.Answer
  5. E
    Apply bilateral soft wrist restraints immediately to prevent physical injury.
  6. F
    Prepare and administer an intravenous (IV) push sedative.

Answer

The correct actions are to direct other clients and visitors to leave the immediate area, maintain a personal distance of at least two arm lengths, and communicate using a calm, low-pitched voice and concise sentences.
When a client exhibits signs of escalating behavior, the immediate priority is milieu safety and de-escalation. Directing other clients and visitors away removes them from potential harm and decreases the audience, which can help calm the escalated client. Maintaining at least two arm lengths of distance protects the nurse from sudden physical strikes. Finally, communicating with a calm, low-pitched voice and using concise sentences provides clear, non-threatening direction without increasing the client's sensory overload.

Step-by-Step Solution

1
Identify the clinical situation from the data collected.
The client is demonstrating signs of acute behavioral escalation and potential aggression, evidenced by rapid pacing, loud speech, and clenched fists.
Recognizing early signs of a behavioral crisis dictates the priority of nursing interventions.
2
Determine the priority nursing goals.
The primary goals are to ensure the safety of the milieu (client, staff, and bystanders) and to attempt non-pharmacological verbal de-escalation.
Safety is always the immediate priority in any psychiatric or behavioral emergency.
3
Evaluate each intervention against safety standards and the PN scope of practice.
Removing bystanders, maintaining distance, and using calm communication promote safety and de-escalation. Asking 'why', using immediate restraints, and administering IV push medications violate therapeutic communication, least restrictive alternative mandates, and the PN scope of practice, respectively.
Nursing interventions must be safe, therapeutic, legally sound, and follow a stepwise approach from least to most restrictive.

Key Concept

Crisis De-escalation and Milieu Safety
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Mental Health Concepts

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