A young adult client admitted to the psychiatric unit with borderline personality disorder approaches the nursing station in a highly agitated state. The client demands immediate use of the staff telephone and threatens self-harm if the request is denied. Which responses and actions are appropriate for the practical nurse (PN) to implement? Select all that apply.
- Maintain a safe physical distance while speaking in a calm, neutral tone.Answer
- Remove any potentially hazardous items from the immediate vicinity.Answer
- Notify the registered nurse (RN) of the client's escalating behavior and threats.Answer
- DInform the client that their behavior is inappropriate and logically explain why the phone is off-limits.
- EConduct an initial suicide risk assessment to evaluate the lethality of the threat.
- FApply soft wrist restraints immediately to prevent the client from self-injury.
Answer
The practical nurse should maintain a safe physical distance, remove hazardous items from the area, and immediately notify the registered nurse of the client's threats and escalation.
During an acute behavioral escalation, the immediate goals are maintaining environmental safety and de-escalating the situation. Maintaining a safe physical distance and speaking in a calm, neutral tone help prevent further agitation. Removing hazardous items protects both the client and staff from impulsive, violent actions. Because the client has verbalized a specific threat of self-harm, the PN must promptly notify the RN, who will conduct a comprehensive risk assessment and determine if the care plan or level of observation needs adjusting.
Step-by-Step Solution
Key Concept
Crisis de-escalation and safety priorities within the PN scope of practice