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Difficulty: HardCrisis Intervention

A client admitted to a dual-diagnosis inpatient unit begins pacing rapidly in the hallway, breathing heavily, and loudly demanding to leave the facility immediately. Which initial actions by the licensed practical nurse (PN) are appropriate? Select all that apply.

  1. Maintain an open, non-threatening posture while standing approximately two arm-lengths away from the client.Answer
  2. Instruct other clients to clear the hallway and remove any mobile equipment from the immediate area.Answer
  3. Acknowledge the client's current emotional state by stating, 'You look very distressed; how can I help you right now?'Answer
  4. D
    Explain the logical reasons why leaving the facility early would negatively impact the client's recovery plan.
  5. E
    Ask the client, 'Why do you suddenly feel the need to leave when you were doing so well earlier today?'
  6. F
    Contact the security team to apply physical restraints to prevent an unauthorized elopement from the unit.

Answer

The appropriate initial actions are to maintain a safe distance with an open posture, clear the hallway of bystanders and hazards, and calmly acknowledge the client's distress.
Effective crisis intervention requires a 'safety first' approach prioritizing least restrictive measures. The correct actions establish physical safety by giving the client adequate space and clearing the milieu of potential victims or hazards. Verbally, the nurse must use simple, validating statements that acknowledge the client's feelings without making demands or asking complex questions.

Step-by-Step Solution

1
Analyze the client's presentation in the scenario.
The client is exhibiting signs of an acute behavioral crisis and escalating agitation (pacing, heavy breathing, loud demands).
Recognizing the current phase of the crisis cycle dictates which interventions are safe and effective.
2
Evaluate the options for immediate physical safety and milieu management.
Maintaining two arm-lengths of distance and clearing the hallway prioritize the physical safety of the nurse, the client, and bystanders.
Safety is the highest priority in any psychiatric emergency or crisis situation.
3
Evaluate the verbal communication options for therapeutic de-escalation.
Acknowledging the distress is therapeutic. Rationalizing or asking 'why' questions are non-therapeutic and counterproductive during active agitation.
An escalating client has impaired cognitive processing; communication must be simple, empathetic, and non-confrontational.
4
Assess the need for restrictive interventions.
Applying restraints immediately is incorrect; least restrictive measures must be exhausted first.
Standards of care dictate that chemical or physical restraints are absolute last resorts.

Key Concept

Crisis De-escalation and Milieu Safety Prioritization
Estimated Time:1m 30s
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Topics

Crisis Intervention

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