A licensed practical nurse (PN) in a long-term care facility is in the dayroom when a resident with a history of aggressive behavior suddenly becomes severely agitated. The resident grabs a heavy metal cane, begins swinging it forcefully, and shouts threateningly at others. Arrange the following interventions in the priority order the PN should implement them, from first to last.
- 1Maintain a safe physical distance from the resident and ensure an unblocked route to the exit.
- 2Evacuate other residents, visitors, and bystanders from the immediate dayroom area.
- 3Notify the charge nurse and activate the facility's emergency response protocol for additional support.
- 4Adopt a non-threatening posture and use a calm, clear voice to attempt verbal de-escalation.
Answer
The correct priority sequence is: 1) Maintain a safe physical distance and ensure an unblocked exit, 2) Evacuate other residents and bystanders, 3) Notify the charge nurse for additional support, and 4) Attempt verbal de-escalation.
In any psychiatric or behavioral crisis involving potential violence, the nurse must apply Maslow's hierarchy of needs and basic safety principles. The absolute first step is self-preservation (maintaining distance and an exit). If the nurse is injured, they cannot help the client or others. The second step is protecting other vulnerable clients and bystanders from imminent harm. The third step is calling for a coordinated team response, as one nurse should never attempt to physically manage an armed, agitated client alone. Finally, once safety parameters are established and help is on the way, the nurse can safely employ verbal de-escalation techniques.
Step-by-Step Solution
Key Concept
Prioritization in Crisis Intervention and De-escalation