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Difficulty: EasyCrisis Intervention

A practical nurse (PN) is caring for a client in the emergency department who suddenly becomes agitated, pacing the hallway, clenching their fists, and shouting at staff. What is the priority action for the nurse to take?

  1. Ensure a safe distance between the client and others while calling for assistance.Answer
  2. B
    Attempt to verbally reason with the client to explain why shouting is inappropriate.
  3. C
    Immediately apply mechanical restraints to prevent the client from causing harm.
  4. D
    Ask the client why they are feeling so upset and aggressive.

Answer

The priority action is to ensure a safe distance between the client and others while calling for assistance.
When a client exhibits non-verbal and verbal cues of escalating agitation, such as pacing, clenched fists, and shouting, the immediate priority for the nurse is physical safety. Maintaining a safe distance and calling for additional personnel ensures the safety of the milieu while preparing a coordinated approach for further de-escalation.

Step-by-Step Solution

1
Assess the situation for immediate threats to physical safety.
The client is pacing, clenching fists, and shouting, indicating a high risk for physical violence.
Safety is always the primary focus during a behavioral crisis.
2
Identify the most appropriate initial intervention based on the priority of safety.
Maintaining a safe distance and calling for help protects everyone involved while preparing for further de-escalation.
Direct confrontation or logical reasoning is ineffective during peak agitation, and restraints are a last resort.

Key Concept

Crisis Intervention: De-escalation and Safety Priorities
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Topics

Crisis Intervention

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