A client on an inpatient psychiatric unit begins pacing rapidly near the medication room, clenching their fists, and shouting loudly. In what order should the practical nurse implement the following interventions? Arrange the actions in the correct sequence, starting with the immediate priority and progressing from least restrictive to most restrictive.
- 1Direct other clients in the vicinity to move to a safe, quiet area.
- 2Attempt verbal de-escalation using a calm, non-confrontational tone of voice.
- 3Offer the client a prescribed as-needed (PRN) oral medication for agitation.
- 4Activate the facility's behavioral emergency response team.
- 5Administer a prescribed as-needed (PRN) intramuscular (IM) antipsychotic medication.
Answer
The correct sequence is to first secure the milieu by moving other clients, then attempt verbal de-escalation, offer voluntary oral medication, call for the behavioral response team, and finally, administer an intramuscular medication only as a last resort.
When managing an escalating behavioral crisis, the nurse must prioritize safety and follow the principle of least restrictive intervention. The first priority is always the safety of bystanders and the milieu, which requires removing other clients from the area. Next, the nurse must attempt the least invasive direct intervention, which is verbal de-escalation. If this is ineffective, offering a voluntary, oral medication is the next appropriate step. If the client continues to escalate and poses a threat, the nurse should call for a behavioral response team (a show of support). Finally, administering an intramuscular medication is considered a chemical restraint and is reserved as a last resort for imminent danger.
Step-by-Step Solution
Key Concept
Least Restrictive Intervention Hierarchy
Estimated Time:1m 30s