A practical nurse (PN) is assigned to a client with a history of severe anxiety on a general medical unit. Upon entering the room, the PN finds the client pacing rapidly, breathing heavily, and shouting aggressively at a television news program. An unlicensed assistive personnel (UAP) is standing near the client's bed and appears frightened. In what order should the PN perform the following interventions? Arrange the actions from first to last.
- 1Maintain a clear physical path to the exit door while observing the client.
- 2Direct the unlicensed assistive personnel (UAP) to safely step out of the room.
- 3Use a calm, low-pitched voice to address the client by name and offer help.
- 4Notify the supervising registered nurse (RN) of the acute behavioral change.
Answer
The correct priority order is to first secure an exit path for personal safety, second direct the UAP out of the room to protect others and reduce stimuli, third initiate verbal de-escalation with a calm voice, and finally notify the supervising RN.
In crisis intervention, safety principles dictate that the physical safety of the nurse and others is paramount. Establishing a clear exit path ensures the nurse is safe to act. Removing the UAP protects a vulnerable bystander and simultaneously reduces environmental stimulation for the agitated client. Once the environment is secure, the practical nurse can safely employ therapeutic communication to attempt de-escalation. Finally, the PN must communicate the acute change to the RN for ongoing management, adhering to the PN scope of practice.
Step-by-Step Solution
Key Concept
Crisis Intervention