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Difficulty: MediumCrisis Intervention

A client at a community health clinic suddenly becomes severely agitated, throwing magazines across the waiting room and shouting, 'Everyone here is trying to trick me!' The client clenches their fists and glares at a practical nurse who is standing nearby. Which action should the nurse take first?

  1. Ensure a clear exit path and direct other individuals away from the immediate area.Answer
  2. B
    Slowly step toward the client to logically explain that the staff is there to help.
  3. C
    Ask the client why they feel they are being tricked by the clinic staff.
  4. D
    Initiate the application of physical restraints to prevent the client from causing injury.

Answer

Ensure a clear exit path and direct other individuals away from the immediate area.
During an active behavioral crisis where a client is demonstrating physical aggression (throwing objects, clenching fists), the first and most critical action is to ensure safety. By maintaining a safe distance, ensuring a clear exit path, and removing bystanders, the nurse protects themselves and others while simultaneously reducing the environmental stimulation that may be contributing to the client's agitation.

Step-by-Step Solution

1
Assess the situation for immediate safety risks.
The client is throwing objects, clenching fists, and shouting, indicating an active behavioral crisis with potential for physical violence.
Recognizing the signs of rapid escalation is necessary to determine the appropriate level of intervention.
2
Prioritize physical safety and environmental management.
The nurse maintains a safe distance, identifies an exit route, and clears bystanders from the area.
In any crisis situation, ensuring the safety of the nurse, the client, and bystanders is the paramount initial action before attempting direct verbal de-escalation.

Key Concept

Crisis Intervention: Prioritizing Safety and De-escalation
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Topics

Crisis Intervention

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