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Difficulty: MediumCrisis Intervention

During a shift on an inpatient mental health unit, a practical nurse observes a client suddenly stand up, clench their fists, and begin shouting aggressively at a peer in the dayroom. Which action should the nurse take first?

  1. Maintain a safe distance, keep a clear path to the exit, and call for additional staff assistance.Answer
  2. B
    Approach the client closely and ask them to explain the reason for their sudden anger.
  3. C
    Tell the client that everything will be fine as long as they sit back down and relax.
  4. D
    Quickly obtain and administer the client's prescribed as-needed (PRN) intramuscular sedative.

Answer

Maintain a safe distance, keep a clear path to the exit, and call for additional staff assistance.
The correct answer emphasizes immediate milieu safety. When a client exhibits active signs of physical escalation (clenching fists, shouting), the priority is to protect all individuals in the environment. Maintaining a safe distance, securing an exit route, and calling for backup ensures physical safety and provides a team approach before attempting focused verbal de-escalation.

Step-by-Step Solution

1
Assess the immediate physical safety of the clinical environment.
The client is demonstrating non-verbal cues of impending violence (clenched fists, aggressive shouting).
Identifying the current phase of the behavioral crisis dictates the appropriate intervention.
2
Prioritize interventions based on the safety of the nurse, the escalating client, and bystanders.
The nurse must secure their own physical safety and obtain backup.
Approaching an agitated, potentially violent client alone poses a severe risk of injury.
3
Select the option that focuses on physical safety and team support before attempting direct de-escalation.
Maintaining distance and calling for help is identified as the best initial action.
This aligns with established crisis intervention protocols emphasizing safety and least restrictive measures.

Key Concept

Prioritization in psychiatric emergencies and milieu safety.
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Topics

Crisis Intervention

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