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Question

Difficulty: HardCoping Mechanisms

A client with end-stage renal disease receives notification that they have been removed from the transplant waiting list. The client is rapidly pacing the room, throwing personal clothing into a duffel bag, and shouting that the medical facility is completely incompetent. Which actions should the practical nurse take? Select all that apply.

  1. Maintain a clear path to the door while standing at a safe distance from the client.Answer
  2. Notify the registered nurse immediately regarding the client's escalating agitation.Answer
  3. State calmly, "I can see you are extremely upset about this news. I am here to listen."Answer
  4. D
    Approach the client to gently touch their arm and explain the medical criteria for transplant eligibility.
  5. E
    Tell the client, "Everything happens for a reason, and you can still have a fulfilling life on dialysis."
  6. F
    Create and initiate a behavioral modification care plan to prevent further aggressive outbursts.

Answer

The correct actions are to maintain a clear path to the door at a safe distance, notify the registered nurse, and calmly offer to listen to the client's frustrations.
The correct actions prioritize safety, scope of practice, and therapeutic communication. Maintaining a clear path to the door and standing at a safe distance protects the nurse during an acute behavioral crisis. Notifying the registered nurse aligns with the practical nurse's responsibility to report escalating distress and potential safety risks immediately. Stating calmly that the nurse sees the client is upset and is there to listen provides therapeutic support and validates the client's feelings without attempting to logically reason with an escalated individual.

Step-by-Step Solution

1
Analyze the clinical scenario to determine the client's current emotional state.
The client is experiencing an acute stress reaction (anger/displacement) resulting in a behavioral crisis, as evidenced by pacing, throwing objects, and shouting.
Identifying the phase of crisis is necessary to select appropriate de-escalation and safety interventions.
2
Evaluate the practical nurse's scope of practice and safety priorities in this context.
The priority is physical safety for both staff and the client, followed by reporting the change in condition to the registered nurse.
Practical nurses must operate within their legal scope, which includes data collection, reinforcing coping mechanisms, and reporting escalations rather than independently formulating new care plans.
3
Review each option for therapeutic value and safety.
Select options that maintain physical distance, utilize empathetic communication without offering false reassurance, and appropriately escalate the situation to the registered nurse.
Logical reasoning or physical touch during severe agitation can trigger violence, while minimizing the client's feelings blocks therapeutic communication.

Key Concept

Crisis Intervention, Therapeutic Communication, and Scope of Practice
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Topics

Coping Mechanisms

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