A client is admitted to the inpatient behavioral health unit with acute mania. The client begins pacing the hallway rapidly, shouting loudly, and kicking empty chairs, but has not physically threatened staff or other clients. An unlicensed assistive personnel (UAP) tells the registered nurse, 'This client is going to hurt someone. We should put them in restraints right now. I will go get the leather straps.' Based on the ethical principle of nonmaleficence and legal client rights, which action is most appropriate for the nurse to take?
- Intervene by utilizing verbal de-escalation techniques and offering the client a prescribed PRN antianxiety medication.Answer
- BDirect the UAP to apply the physical restraints while the nurse immediately contacts the healthcare provider for an emergency order.
- CInform the client that physical restraints will be applied immediately if the destructive behavior continues.
- DInstruct the UAP to evaluate the client's emotional state to determine the underlying cause of the agitation.
Answer
The nurse must prioritize interventions that minimize restriction by first attempting verbal de-escalation and offering a prescribed PRN medication.
Clients in behavioral health settings retain their legal and ethical right to receive care in the least restrictive environment. The ethical principles of nonmaleficence (doing no harm) and respect for human dignity dictate that the nurse must prioritize interventions that minimize restriction while maintaining unit safety. Because the client has not physically harmed anyone, the nurse is ethically and legally required to first attempt less restrictive alternatives, such as verbal de-escalation, reducing environmental stimuli, or offering a prescribed PRN medication. Physical restraints are strictly a measure of last resort.
Step-by-Step Solution
Key Concept
Ethical Practice: Least Restrictive Environment