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Difficulty: MediumBehavioral Interventions

During a shift in a neurological rehabilitation unit, a client with a traumatic brain injury becomes intensely agitated after a sudden schedule change. The client begins pacing the hallway rapidly, clenching their fists, and shouting at staff. Arrange the following nursing interventions in the correct sequence, prioritizing from least restrictive to most restrictive.

  1. 1Employ verbal de-escalation techniques using a calm, supportive tone.
  2. 2Offer the client a voluntary transition to a quiet, low-stimulation room.
  3. 3Administer a prescribed as-needed (PRN) oral sedative medication.
  4. 4Administer a prescribed intramuscular (IM) medication for severe agitation.
  5. 5Apply mechanical restraints to prevent imminent physical harm.

Answer

The correct sequence from least to most restrictive is: verbal de-escalation, voluntary environmental modification, oral PRN medication, IM chemical restraint, and finally mechanical restraints.
Behavioral management follows a strict hierarchy designed to protect client rights, dignity, and safety. The nurse must always begin with the least restrictive intervention (verbal de-escalation), progress to environmental changes (quiet room), step up to voluntary chemical interventions (oral medication), move to rapid-acting chemical restraints (IM medication), and only use physical interventions (mechanical restraints) as a final, emergency option to prevent imminent harm.

Step-by-Step Solution

1
Identify the least restrictive and least invasive intervention.
Select verbal de-escalation techniques.
Standard behavioral guidelines require starting with non-physical, non-chemical communication to help the client regain control independently.
2
Determine the next level of intervention involving the milieu.
Select offering a voluntary transition to a quiet room.
Environmental modification is slightly more restrictive than simple conversation but still relies on voluntary client cooperation.
3
Identify the least invasive pharmacological intervention.
Select administering a prescribed PRN oral sedative.
Voluntarily taking an oral medication is less invasive and less restrictive than receiving an involuntary or rapid-acting injection.
4
Determine the next pharmacological step if severe agitation persists.
Select administering a prescribed IM medication.
IM injections are considered a chemical restraint when used to rapidly manage severe agitation, making them highly restrictive.
5
Identify the most restrictive safety intervention.
Select applying mechanical restraints.
Physical or mechanical restraints completely eliminate the client's mobility and are only legally and ethically permissible as a final alternative to prevent imminent injury.

Key Concept

Hierarchy of Restrictive Interventions
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Topics

Behavioral Interventions

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