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Question

Difficulty: MediumBehavioral Interventions

A licensed practical nurse (LPN) is caring for a client who recently received a terminal prognosis. As the nurse enters the room, the client suddenly becomes verbally aggressive, throws a plastic water pitcher against the wall, and yells, "Get out of here!" Which action should the nurse take first?

  1. Maintain a safe physical distance and ensure a clear, unobstructed path to the doorway.Answer
  2. B
    Ask the client why they are throwing objects and encourage them to explain their frustration.
  3. C
    State firmly that throwing objects is unacceptable and violates the facility's code of conduct.
  4. D
    Leave the room immediately to request a prescription for an emergency chemical restraint.

Answer

The correct action is to maintain a safe physical distance and ensure a clear, unobstructed path to the doorway.
In an active behavioral crisis where a client is demonstrating physical aggression (e.g., throwing objects), the absolute first priority is personal and milieu safety. By maintaining a safe physical distance and ensuring a clear path to the door, the nurse protects themselves from injury and prevents the client from feeling physically trapped. This foundational safety measure must be established before the nurse can effectively attempt verbal de-escalation or assess the underlying cause of the distress.

Step-by-Step Solution

1
Assess the immediate environment and the client's current behavioral state.
The client is actively aggressive, throwing objects, and highly agitated.
Rapid situational assessment is necessary to identify immediate threats to safety.
2
Determine the priority of care based on the assessment.
Physical safety for both the nurse and the client takes priority over communication, limit-setting, or medication administration.
In any behavioral crisis, securing the environment and ensuring staff safety is the foundational step before attempting de-escalation.
3
Implement the safest least-restrictive intervention.
The nurse steps back, avoids cornering the client, and ensures the exit is accessible.
This establishes a safe milieu, minimizes the threat level, and positions the nurse to safely initiate verbal de-escalation once the physical danger is mitigated.

Key Concept

Crisis Intervention and Immediate Safety Priorities
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Topics

Behavioral Interventions

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