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Difficulty: MediumBehavioral Interventions

During morning rounds on a respiratory care unit, a client with a history of severe anxiety disorder suddenly removes their oxygen cannula, throws a water pitcher against the wall, and screams that the room is shrinking. Which of the following is the priority behavioral intervention for the nurse to implement?

  1. Position oneself near the room's exit and use a soft, steady voice to acknowledge the client's distress.Answer
  2. B
    Logically explain to the client that the room dimensions have not changed and they are completely safe.
  3. C
    Request an immediate order for a chemical restraint to prevent the client from further escalating.
  4. D
    Tell the client not to worry because the nursing staff will not let anything bad happen to them.

Answer

Position oneself near the room's exit and use a soft, steady voice to acknowledge the client's distress.
When a client is actively escalating and exhibiting violent behavior, the nurse's immediate priority is personal and environmental safety. Maintaining an open exit path ensures the nurse is not trapped. Using a calm, non-threatening approach is the standard initial step in the least-restrictive intervention hierarchy, helping to de-escalate the client's panic without immediate force or medication.

Step-by-Step Solution

1
Assess the environment and identify the phase of the behavioral crisis.
The client is in the active escalation phase, demonstrating physical aggression by throwing objects.
Accurate assessment of the crisis level dictates the appropriate intervention hierarchy and safety needs.
2
Determine the most appropriate initial intervention based on safety and least-restrictive principles.
The nurse must secure a safe position near the exit and attempt verbal de-escalation.
Physical safety of the staff must be established first, followed immediately by non-threatening verbal techniques to calm the client before considering more restrictive measures.

Key Concept

Crisis Safety and De-escalation Priorities
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Topics

Behavioral Interventions

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