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Difficulty: MediumSubstance Use and Other Disorders

A client in a behavioral health unit is undergoing detoxification from chronic methamphetamine use. The client abruptly exhibits severe psychomotor agitation, begins forcefully throwing magazines across the dayroom, and shouts aggressively at peers. Which action is the priority for the practical nurse (PN)?

  1. A
    Explain rationally to the client that throwing objects violates the unit's safety rules.
  2. Direct the other clients to leave the dayroom immediately.Answer
  3. C
    Tell the client, "Everything is going to be okay if you just take a deep breath."
  4. D
    Obtain assistance to apply physical restraints to prevent further property damage.

Answer

Direct the other clients to leave the dayroom immediately.
In a behavioral crisis involving severe agitation and potential violence, the nurse's absolute priority is the physical safety of all individuals on the unit. Removing other clients from the immediate vicinity protects them from harm and reduces the overall stimulation in the environment. This is the essential first step before attempting to de-escalate the agitated client or calling for a crisis response team.

Step-by-Step Solution

1
Analyze the clinical situation presented in the scenario.
The client is in the active phase of a behavioral crisis secondary to methamphetamine detoxification, posing an immediate physical threat to the surrounding milieu.
Identifying the severity and phase of the crisis dictates the appropriate level of nursing intervention.
2
Determine the appropriate priority framework to apply.
Apply the safety and risk reduction framework.
When a client is acting aggressively and unpredictably, physiological needs are temporarily superseded by the immediate necessity to protect bystanders, staff, and the client from physical injury.
3
Select the nursing intervention that best addresses the priority.
The most immediate and effective way to ensure safety is to remove potential targets (the other clients) from the dayroom.
This action immediately secures the environment, protects vulnerable individuals, and decreases sensory stimulation without requiring direct physical contact with the agitated client.

Key Concept

Crisis Intervention and Milieu Safety
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Topics

Substance Use and Other Disorders

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