A practical nurse (PN) observes a client on the psychiatric unit pacing rapidly in the hallway, clenching their fists, and muttering angrily. In which order should the PN implement the following de-escalation interventions? Arrange from first action to last.
- 1Ensure a safe distance and remove any potentially dangerous objects from the area
- 2Verbally engage the client using a calm, soft, and non-threatening tone
- 3Offer the client choices, such as moving to a quiet room or taking a prescribed oral PRN medication
- 4Request additional staff assistance if the client's agitation continues to escalate
Answer
The correct sequence is to first ensure environmental safety, then use verbal de-escalation techniques, followed by offering therapeutic choices, and finally requesting staff assistance if the situation worsens.
In crisis management, the nurse must apply the principle of least-restrictive interventions while maintaining safety. The first step is securing the environment by maintaining a safe distance and removing hazards. Next, verbal de-escalation is used as the primary, non-invasive tool to calm the client. If verbal engagement alone is insufficient, offering choices (like a quiet area or prescribed PRN medication) is the next least-restrictive step to help the client regain control. Finally, if these measures fail and the agitation worsens, requesting additional staff assistance is necessary to maintain a safe environment.
Step-by-Step Solution
Key Concept
Crisis de-escalation and least-restrictive interventions