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Difficulty: MediumCrisis Intervention

A client on an inpatient rehabilitation unit receives news of permanent mobility deficits following a spinal injury. The client becomes highly agitated, paces the room rapidly, throws a water pitcher at the wall, and yells, "My life is over!" The client's roommate is resting in the adjacent bed. Which action should the practical nurse take first?

  1. Remove the roommate from the immediate area and call for additional staff support.Answer
  2. B
    Prepare to administer a prescribed as-needed intramuscular sedative.
  3. C
    Assure the client by stating, "Medical technology is advancing, and you will find a way to adapt."
  4. D
    Remind the client that aggressive behavior violates the facility's code of conduct.

Answer

The priority action is to remove the roommate from the immediate area and call for additional staff support.
During an acute behavioral crisis involving property damage and severe agitation, the nurse's first priority is always physical safety. Removing the roommate protects an innocent bystander from potential injury, and calling for additional support ensures there are adequate resources to safely manage the environment before attempting verbal de-escalation.

Step-by-Step Solution

1
Assess the immediate environment for safety threats.
The nurse identifies that the client is throwing objects (water pitcher) and an innocent bystander (the roommate) is in harm's way.
Safety of the milieu is the absolute priority in any crisis intervention scenario.
2
Implement the least restrictive intervention that ensures immediate safety.
The nurse removes the roommate from the room and signals for staff assistance.
Removing potential targets and increasing staff presence helps contain the situation without prematurely resorting to physical or chemical restraints.
3
Once safety is established, begin verbal de-escalation.
Additional staff arrives, and the nurse can safely attempt to verbally de-escalate the client from a safe distance.
Therapeutic communication can only be effective once the physical environment is secure and the immediate threat to others is neutralized.

Key Concept

Crisis Intervention: Environmental Safety and Prioritization
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Topics

Crisis Intervention

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