Examkin

Question

Difficulty: HardBehavioral Interventions

A resident in a long-term care facility is exhibiting escalating psychomotor agitation, shouting at staff members, and forcefully refusing initial redirection. The practical nurse (PN) is planning the care approach to safely manage the client's behavior. Arrange the following interventions in order from the least restrictive to the most restrictive approach.

  1. 1Employ verbal de-escalation techniques using a calm, non-confrontational tone.
  2. 2Offer the client an opportunity to relocate to a quiet, low-stimulus area.
  3. 3Provide a prescribed as-needed (PRN) oral sedative medication.
  4. 4Administer a prescribed as-needed (PRN) intramuscular (IM) antipsychotic medication.
  5. 5Assist the behavioral response team in applying prescribed mechanical restraints.

Answer

The correct sequence from least to most restrictive is: 1) Employ verbal de-escalation techniques, 2) Offer relocation to a quiet area, 3) Provide a prescribed PRN oral sedative, 4) Administer a prescribed PRN IM antipsychotic, and 5) Assist in applying mechanical restraints.
The correct sequence prioritizes the client's legal right to the least restrictive environment. Verbal de-escalation and environmental changes must be exhausted before moving to chemical interventions (first oral, then IM). Physical restraints are only legally and ethically permissible when all other measures fail and there is an imminent threat to safety.

Step-by-Step Solution

1
Identify the primary legal and ethical goal of the interventions.
The goal is to maintain milieu safety while strictly adhering to the principle of least restrictive environments.
Nursing standards mandate that clients have the right to be treated with the least restrictive means necessary to ensure safety.
2
Determine the least invasive initial step.
Verbal de-escalation and therapeutic communication form the baseline for managing agitation.
Establishing rapport and validating feelings can frequently de-escalate a situation without requiring further restriction of movement or autonomy.
3
Evaluate the next step if verbal communication is insufficient.
Modifying the environment by relocating the client to a low-stimulus area follows verbal attempts.
This is a non-pharmacological method of behavioral control that distances the client from triggers.
4
Sequence the pharmacological and physical interventions.
Oral medications precede intramuscular injections, and physical restraints are the absolute final option.
Voluntary oral intake is less invasive than forced or IM chemical restraints. Any chemical intervention is generally preferred over physical mechanical restraints due to the high risk of injury and trauma associated with physical restraints.

Key Concept

Hierarchy of Least Restrictive Interventions
Rate this question

Topics

Behavioral Interventions

More questions from this topic