A practical nurse (PN) is preparing morning medications in a substance use detoxification unit. A client approaches the medication window, loudly demands to be discharged immediately, bangs a fist on the counter, and stands aggressively close to another client who is waiting. Which immediate actions should the PN take? Select all that apply.
- Set clear, concise limits regarding the disruptive behaviors using a neutral toneAnswer
- Direct the bystander client to safely relocate to the dayroomAnswer
- Maintain a physical distance of at least two arm lengths from the agitated clientAnswer
- DExplain the facility's step-by-step discharge protocols to help the client understand the delay
- EProvide reassurance that the situation is not a big deal and will be resolved shortly
- FRequest an immediate prescription for a chemical restraint to prevent further escalation
Answer
The practical nurse should maintain a physical distance of at least two arm lengths, direct the bystander client to safely relocate, and set clear, concise limits using a neutral tone.
Managing an escalating client requires immediate attention to safety and the use of least-restrictive interventions. Relocating bystanders protects other clients, maintaining physical distance protects the nurse, and setting clear, neutral limits provides structure without provoking further aggression.
Step-by-Step Solution
Key Concept
Milieu Safety and Verbal De-escalation