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Difficulty: HardCrisis Intervention

While working in a residential step-down facility, a practical nurse observes a client who has just received a distressing telephone call from relatives. The client hurls the phone across the room, begins pacing frantically, hyperventilating, and striking a padded wall repeatedly with closed fists. Which action should the nurse prioritize?

  1. Ensure an unobstructed personal exit route while quietly clearing loose chairs from the immediate area.Answer
  2. B
    Instruct the client to stop hitting the wall while explaining logically that aggressive behavior will not resolve the family issue.
  3. C
    Reassure the client that the family situation will improve soon and ask why they are reacting so violently.
  4. D
    Initiate a physical hold on the client's arms to immediately halt the behavior and prevent tissue trauma to their hands.

Answer

Ensure an unobstructed personal exit route while quietly clearing loose chairs from the immediate area.
During an acute behavioral escalation, the immediate clinical priority is always physical safety. Securing a personal exit path ensures the nurse cannot be cornered or trapped. Quietly removing loose objects (like chairs) prevents them from being used as weapons or causing accidental injury. Because the client is striking a padded wall, the immediate risk of severe tissue trauma is reduced, allowing the nurse to safely manage the environment rather than prematurely engaging in dangerous physical intervention or ineffective verbal correction.

Step-by-Step Solution

1
Analyze the client's behavioral state.
The client is in an acute, escalated phase of a situational crisis, demonstrating severe agitation and physical acting out.
Identifying the crisis phase dictates the appropriate level of intervention, ruling out interventions that require the client to process logic.
2
Evaluate the immediate risks in the environment.
The client is hitting a padded wall, which presents a lower risk of severe physical trauma, but loose furniture (chairs) poses a risk for becoming projectiles.
Environmental assessment determines the true physical threat level to both the client and the staff.
3
Determine the highest priority intervention based on safety protocols.
The nurse must secure their own safety by maintaining a clear exit and protect the client by removing environmental hazards.
In any behavioral crisis, ensuring the physical safety of the milieu without unnecessarily provoking the client is the absolute first priority.

Key Concept

Crisis Intervention: Environmental Safety and De-escalation
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Topics

Crisis Intervention

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