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Difficulty: HardStress Management

A pediatric intensive care nurse is caring for a child who sustained a severe head injury three weeks ago. The child's parent, who has remained continuously at the bedside, suddenly stands up, forcefully knocks a chair over, and shouts, "You are all doing nothing! I cannot take another second of watching my child like this!" The parent is visibly trembling and pacing rapidly near the client's life-sustaining equipment. Which of the following is the priority nursing action?

  1. Maintain a safe distance, ensure an unobstructed path to the door, and calmly state, "You are feeling incredibly overwhelmed right now."Answer
  2. B
    Approach the parent, gently touch their arm, and reassure them that the medical team is providing the best possible care.
  3. C
    Ask the parent why they are suddenly feeling so upset today after remaining calm for the past several weeks.
  4. D
    Instruct the parent to immediately leave the room and wait in the family lounge until they can control their emotions.

Answer

The priority action is to maintain a safe physical distance, ensure the nurse's path to the exit is clear, and use therapeutic communication to acknowledge the parent's overwhelmed state.
The client's parent is experiencing an acute situational crisis and a severe stress response, escalating to physical agitation. The highest priority is safety for all individuals in the room. The nurse must first ensure their own safety by maintaining physical distance and keeping an open path to the exit. Simultaneously, the nurse must use therapeutic communication (validation and reflection) to begin de-escalating the parent's acute stress.

Step-by-Step Solution

1
Assess the situation for immediate safety threats to the client, staff, and the parent.
The parent is exhibiting severe acute stress, physical agitation (knocking over a chair, pacing), and emotional lability near critical equipment.
According to Maslow's Hierarchy of Needs, physiological safety is the highest priority in any escalating psychiatric or stress-induced crisis.
2
Determine the most appropriate initial intervention that addresses both safety and the psychological crisis.
The nurse must protect themselves by keeping an open exit while simultaneously initiating verbal de-escalation techniques.
Maintaining distance prevents physical injury, while validating the parent's feelings helps de-escalate the acute stress response without provoking defensiveness.

Key Concept

Crisis Intervention and De-escalation Techniques
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Topics

Stress Management

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