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Difficulty: MediumMental Health Concepts

An older adult resident in a long-term memory care facility begins pacing the hallway rapidly, clenching their fists, and glaring at other individuals. The resident loudly states, 'Everyone is plotting against me, and I will not let it happen!' Which action should the practical nurse (PN) take first?

  1. Approach the resident calmly from a slight angle and offer to walk together to a quiet, low-stimulation environment.Answer
  2. B
    Document the sudden behavioral change as a normal, expected progression of age-related cognitive decline.
  3. C
    Attempt to clarify the delusion by asking the resident exactly why they feel threatened by the others.
  4. D
    Apply a soft physical restraint to a chair to prevent the resident from becoming exhausted or injuring others.

Answer

The correct action is to approach the resident calmly and offer to relocate them to a quiet, low-stimulation environment.
Approaching the individual calmly from a slight angle (which is non-threatening) and guiding them to a quiet area is the priority de-escalation technique. This action prioritizes safety, uses the least restrictive intervention available, and helps reduce the sensory overload that may be fueling the paranoia and agitation.

Step-by-Step Solution

1
Analyze the client's behavior and the clinical environment.
The resident is demonstrating signs of severe agitation, paranoia, and potential escalation toward violence.
Recognizing the phase of behavioral escalation is necessary to determine the appropriate intervention.
2
Determine the immediate priority of care.
The priority is to maintain the safety of the resident, staff, and milieu using the least restrictive means possible.
Safety and the principle of least restrictive intervention are foundational to psychiatric nursing care.
3
Select the most appropriate nursing action.
Relocating the client to a low-stimulation area removes triggers and audience, facilitating de-escalation without physical force.
This approach addresses the immediate safety risk while respecting the client's autonomy and avoiding non-therapeutic communication or premature restraints.

Key Concept

Crisis De-escalation and Least Restrictive Interventions
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Topics

Mental Health Concepts

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