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Question

Difficulty: EasyCrisis Intervention

An older adult client in an assisted living facility becomes suddenly agitated, shouting loudly and throwing magazines across the common room. Which action should the practical nurse (PN) take first?

  1. A
    Ask the client to sit down and logically explain the reason for the sudden anger
  2. Maintain a safe distance and ensure a clear, unblocked path to the room's exitAnswer
  3. C
    Warn the client that physical restraints will be applied if the behavior continues
  4. D
    Firmly instruct the client that throwing objects is strictly against facility rules

Answer

Maintain a safe distance and ensure a clear, unblocked path to the room's exit
During an active behavioral crisis involving physical agitation (such as throwing objects), the nurse's immediate priority is safety. Maintaining a safe distance and ensuring an unblocked exit path protects the nurse from potential injury and prevents the client from feeling trapped, which is essential before initiating any verbal de-escalation.

Step-by-Step Solution

1
Assess the situation to identify the current phase of the client's crisis.
The client is actively agitated, shouting, and throwing objects.
Recognizing the active escalation phase determines the immediate level of intervention required.
2
Determine the highest priority of care based on the assessment.
Physical safety for the nurse, the client, and bystanders is the absolute highest priority.
Before any therapeutic communication or medical intervention can occur, the environment must be safe.
3
Select the intervention that best secures safety without escalating the client further.
Maintaining a safe distance and keeping an exit clear protects the nurse and prevents the client from feeling cornered.
This establishes a safe foundation to begin verbal de-escalation techniques.

Key Concept

Prioritizing physical safety and environment security during a behavioral crisis
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Topics

Crisis Intervention

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