Examkin

Question

Difficulty: HardBehavioral Interventions

A client on an acute inpatient behavioral health unit has a history of impulsive actions and poor emotional regulation. The client approaches the practical nurse in the communal dining area and demands an extra meal tray. When the nurse explains that meal service has ended, the client's face flushes, they step within inches of the nurse's face, and shout aggressively, "You are the worst nurse here! I am going to make sure you lose your job!" Which action by the practical nurse is the most appropriate initial intervention?

  1. A
    Say, "You appear very frustrated. Let's go to the quiet room together so you can talk about what is upsetting you."
  2. B
    Ask the client, "Why do you feel the need to threaten my job over a meal tray?"
  3. Step back to increase personal space and state clearly, "I want to help you, but I will not interact with you while you are yelling."Answer
  4. D
    Immediately activate the unit emergency alarm and instruct staff to prepare the seclusion room.

Answer

Step back to increase personal space and state clearly, "I want to help you, but I will not interact with you while you are yelling."
The correct answer demonstrates the fundamental principles of behavioral de-escalation: prioritizing physical safety and establishing clear, firm boundaries. By stepping back, the nurse immediately addresses the safety risk posed by the client encroaching on their personal space. By calmly stating that interaction will not occur while yelling continues, the nurse sets a clear limit on the unacceptable behavior without engaging in a power struggle or arguing.

Step-by-Step Solution

1
Assess the immediate situation for safety risks.
The client is actively escalating, showing physical signs of anger (flushing), and invading the nurse's personal space (stepping within inches).
Maintaining physical safety for both the nurse and the client is the highest priority during behavioral crises.
2
Identify the most appropriate de-escalation technique for the current phase of behavior.
The nurse must use a combination of physical distancing and clear, firm limit-setting.
During active verbal aggression, therapeutic exploration of feelings is ineffective. The client needs concrete boundaries to help them regain emotional control.
3
Select the option that applies the least restrictive intervention while ensuring safety.
Stepping back and stating boundaries is chosen over premature seclusion, arguing, or asking 'why' questions.
It protects the nurse physically and adheres to the ethical principle of using the least restrictive alternative first.

Key Concept

Behavioral Interventions: Limit-Setting and De-escalation
Rate this question

Topics

Behavioral Interventions

More questions from this topic