A practical nurse (PN) is observing a client with schizophrenia who becomes highly agitated in the mental health unit dayroom. The client is pacing rapidly, clenching their fists, and shouting, 'I have to do what the voices say!' In which order should the PN perform the following interventions? Arrange the actions from first to last.
- 1Maintain a safe distance from the client and ensure a clear, unblocked path to the exit.
- 2Direct other clients and bystanders to calmly leave the dayroom.
- 3Decrease environmental stimulation by turning off the television and radio.
- 4Ask the client directly and calmly what the voices are commanding them to do.
- 5Offer the client their prescribed PRN oral antipsychotic medication.
Answer
The PN must prioritize immediate physical safety for themselves and bystanders, followed by environmental de-escalation, assessment of the command hallucinations, and finally pharmacological intervention.
The correct sequence follows the hierarchy of safety and crisis management. Personal safety is paramount, followed immediately by the safety of bystanders. Once physical safety is assured, environmental de-escalation is applied to calm the situation. Only after the environment is secure should the nurse engage in direct clinical assessment of the psychotic symptoms, which then guides the administration of targeted pharmacological interventions.
Step-by-Step Solution
Key Concept
Prioritization of physical safety and crisis de-escalation over immediate clinical assessment.
Estimated Time:1m 30s