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Difficulty: MediumCrisis Intervention

A client on a behavioral health unit becomes physically aggressive after learning their off-unit privileges have been revoked. The client begins striking the corridor walls with closed fists, pacing rapidly, and shouting threats. The practical nurse is currently in the corridor near the client. Which action should the nurse take first?

  1. Maintain a distance of at least two arm lengths while securing a clear path to the nearest exit.Answer
  2. B
    Calmly explain the logical reasons behind the provider's decision to revoke the off-unit privileges.
  3. C
    Ask the client to describe exactly why this specific restriction is causing so much anger.
  4. D
    Initiate the application of physical restraints to prevent the client from damaging the facility walls.

Answer

Maintain a distance of at least two arm lengths while securing a clear path to the nearest exit.
During the active escalation phase of a behavioral crisis, the absolute priority is the physical safety of the nurse, the client, and others in the milieu. Maintaining distance prevents physical injury, and keeping an exit path open ensures the nurse cannot be trapped by an aggressive client.

Step-by-Step Solution

1
Assess the immediate environment for physical safety risks.
Identifies that the client is physically aggressive and the nurse is in close proximity in the corridor.
Safety of the nurse, the client, and others is the primary foundation of crisis intervention.
2
Determine the phase of the crisis.
Recognizes the client is in the active escalation phase, where cognitive processing is minimal.
Interventions must match the client's current ability to process information and their physical threat level.
3
Select the most appropriate initial intervention.
Prioritizes creating physical distance and establishing an escape route.
Protects against sudden physical assault before attempting further verbal de-escalation or calling for a team response.

Key Concept

Crisis Safety and Immediate De-escalation Priorities
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Topics

Crisis Intervention

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