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Difficulty: Very hardCrisis Intervention

A practical nurse (PN) in a long-term care facility is caring for a client who recently learned of a family member's sudden death. The client becomes acutely agitated, begins pacing the hallway rapidly, clenches their fists, and shouts profanities at staff members. Suddenly, the client picks up a heavy dining chair and holds it above their head. Which of the following is the most appropriate immediate action for the PN to take?

  1. Clear all other residents from the immediate area, maintain a safe distance near an exit, and activate the facility's emergency response protocol.Answer
  2. B
    Approach the client slowly with open, visible hands, acknowledge their grief, and gently ask them to put the chair down.
  3. C
    Stand directly in front of the client to block them from advancing, maintain firm eye contact, and ask, 'Why are you acting this way?'
  4. D
    Instruct unlicensed assistive personnel to surround the client to prevent movement and prepare to administer a prescribed PRN sedative.

Answer

The correct action is to clear all other residents from the immediate area, maintain a safe distance near an exit, and activate the facility's emergency response protocol.
When a client escalates to holding a potential weapon (such as a heavy chair), they have entered the active acting-out phase of a crisis. At this stage, logical reasoning and standard verbal de-escalation are highly ineffective, and approaching the client is exceptionally dangerous. The immediate priority is the physical safety of all individuals present. The nurse must evacuate bystanders, maintain a safe distance while ensuring an unblocked exit, and call for emergency assistance to safely manage the situation.

Step-by-Step Solution

1
Assess the client's phase in the crisis escalation cycle.
The client holding a heavy chair above their head indicates the active acting-out (violence) phase, posing an immediate physical threat.
Interventions must match the specific phase of crisis escalation, as strategies effective in early stages are dangerous in later stages.
2
Determine the priority of care based on the immediate threat.
The primary focus shifts entirely from verbal therapeutic de-escalation to strict environmental and personal safety.
When a client is armed or actively violent, verbal interventions are generally ineffective and physical proximity is exceedingly dangerous.
3
Select the intervention that maximizes safety for all individuals.
Evacuating bystanders, securing an escape route for the nurse, and calling for specialized help is the safest appropriate action.
This protects vulnerable bystanders, ensures the nurse's physical safety, and mobilizes the necessary resources to manage a physical crisis without premature use of restraints.

Key Concept

During the active violence phase of a crisis, immediate environmental safety, maintaining distance, and activating emergency protocols supersede attempts at verbal de-escalation or reasoning.
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Crisis Intervention

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