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Question

Difficulty: MediumBehavioral Interventions

A client admitted for intravenous antibiotic therapy has a documented history of bipolar disorder. Staff observe the client rapidly pacing the unit hallway, singing at a disruptive volume, and actively attempting to remove their hospital gown. Which intervention should the practical nurse implement immediately?

  1. Escort the client to their private room while offering a blanket in a calm, firm tone.Answer
  2. B
    Instruct assistive personnel to hold the client's hands to prevent them from undressing.
  3. C
    Ask the client to sit down and explain why they feel the urge to pace and undress.
  4. D
    Warn the client that they will be transferred to a psychiatric unit if the behavior continues.

Answer

Escort the client to their private room while offering a blanket in a calm, firm tone.
The client is demonstrating signs of acute manic escalation. The immediate priorities are to decrease environmental stimulation, prevent the behavior from escalating further, and protect the client's dignity. Escorting the client to a quiet, private area and using a calm, directive tone achieves these goals using the least restrictive method possible.

Step-by-Step Solution

1
Assess the client's behavioral state and the immediate environment.
The client is exhibiting hyperactive, manic behavior (pacing, singing) and is at risk of compromising their own dignity (removing gown) in a public hallway.
Rapid assessment identifies safety concerns, privacy issues, and the level of environmental stimulation.
2
Determine the least restrictive intervention to manage the behavior.
Providing calm, clear direction and moving the client away from the stimulating hallway is the best initial approach.
Nursing standards require the use of the least restrictive alternative to maintain safety and de-escalate crisis situations.
3
Implement the prioritized behavioral intervention.
The nurse escorts the client to a private room, decreasing stimuli while offering a blanket to cover them.
This protects the client's privacy, removes the audience, and uses a therapeutic, non-threatening approach to regain behavioral control.

Key Concept

De-escalation of Manic Behavior
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Topics

Behavioral Interventions

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