A licensed practical nurse (PN) is providing care in an emergency department observation unit. A client becomes highly frustrated about prolonged wait times, begins pacing the room with clenched fists, and angrily shouts at a phlebotomist who has just entered. In which order should the PN perform the following actions? Arrange the steps from first to last.
- 1Position oneself to maintain a safe distance and a clear path to the room's exit.
- 2Direct the phlebotomist to immediately step out of the room.
- 3Use a calm, low-pitched voice to acknowledge the client's frustration.
- 4Notify the supervising registered nurse (RN) of the behavioral escalation.
Answer
The correct sequence of actions prioritizes immediate safety first, followed by environmental management, verbal de-escalation, and finally reporting: 1) Position oneself to maintain a clear exit path, 2) Direct the phlebotomist to leave the room, 3) Use a calm voice to acknowledge the client's frustration, and 4) Notify the supervising RN.
In crisis intervention, safety is always the paramount concern. The nurse must first secure their own safety (clear exit), then secure the safety of others (removing the phlebotomist), which also serves to decrease environmental stimulation. Only after safety is established should the nurse attempt direct verbal de-escalation. Finally, within the PN scope of practice, communicating the acute change in behavior to the RN is required for ongoing care management.
Step-by-Step Solution
Key Concept
Crisis Intervention and De-escalation Priorities