During the evening shift on a behavioral health unit, a client with a history of borderline personality disorder begins yelling at the nursing staff and demanding immediate discharge. The client starts throwing magazines across the dayroom. Arrange the following nursing interventions in the correct sequence from least restrictive to most restrictive. All options must be used.
- 1Approach the client using a calm tone and acknowledge their visible frustration.
- 2Escort the client to a quiet area away from the dayroom to decrease environmental stimulation.
- 3Offer the client a prescribed PRN oral anti-anxiety medication.
- 4Apply prescribed physical restraints if the client attempts to physically harm staff or themselves.
Answer
The correct sequence from least to most restrictive is: verbal de-escalation, environmental modification, oral pharmacological intervention, and finally physical restraints.
In psychiatric and behavioral health nursing, the principle of the least restrictive intervention dictates the sequence of actions when managing an escalating client. The nurse must begin with the least invasive method, which is verbal de-escalation and active listening. If this fails, the next step is environmental modification, such as moving the client to a low-stimulation area. If non-pharmacological methods are insufficient, a chemical intervention (like an oral PRN medication) is offered. Physical restraints are the absolute most restrictive measure and are reserved only for situations where there is an imminent threat to life or safety.
Step-by-Step Solution
Key Concept
Least Restrictive Environment and Behavioral Interventions
Estimated Time:1m 15s