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Difficulty: Very hardBehavioral Interventions

A young adult client is brought to the emergency department via police after being found wandering in traffic. The client is currently in an examination room, highly agitated, hyperventilating, and throwing medical supplies onto the floor. When staff approach, the client screams, 'They are coming to take me away!' Which of the following initial actions by the nurse are appropriate? Select all that apply.

  1. Approach the client from a 45-degree angle while maintaining a distance of at least two arm lengths.Answer
  2. Remove non-essential medical equipment from the immediate area and ensure other individuals are cleared.Answer
  3. Speak using short, concrete sentences such as 'You are safe in the hospital, and I am here to help you.'Answer
  4. D
    Delegate an unlicensed assistive personnel (UAP) to remain inside the room to provide continuous one-to-one observation.
  5. E
    Position a staff member squarely in the doorway to block the exit and prevent the client from fleeing into the emergency department.
  6. F
    Request an immediate prescription for four-point physical restraints to stop the client from throwing additional objects.

Answer

The correct actions are approaching from a 45-degree angle at a safe distance, removing non-essential equipment and clearing the area, and using short, concrete sentences to communicate safety.
The correct interventions prioritize safety and utilize the least restrictive measures for an acutely agitated and paranoid client. Approaching from a 45-degree angle at a safe distance is non-threatening and respects personal space boundaries. Removing objects that can be thrown and clearing the immediate area ensures physical safety for everyone while simultaneously reducing environmental stimulation. Using short, concrete sentences is essential because severe anxiety and paranoia impair a client's cognitive ability to process complex information.

Step-by-Step Solution

1
Assess the client's clinical presentation and identify safety risks.
The client is highly agitated, experiencing paranoia, and demonstrating physical escalation by throwing objects.
An accurate behavioral assessment dictates the appropriate level of intervention, ensuring safety for both the client and the healthcare team.
2
Select interventions that follow the principle of the least restrictive environment.
The nurse utilizes non-threatening body positioning (45-degree angle, ample distance) and clear, concrete verbal reassurance.
These techniques de-escalate the situation by reducing the client's perceived threat without imposing unnecessary physical boundaries.
3
Modify the physical environment to mitigate immediate hazards.
Medical equipment is removed from the room, and unnecessary personnel are cleared.
Removing potential projectiles minimizes injury risk, while decreasing environmental stimuli helps lower the client's severe panic.
4
Evaluate and reject unsafe or overly restrictive interventions.
Options involving delegating to a UAP, physically blocking the exit, and jumping directly to physical restraints are eliminated.
These actions violate safety protocols, inappropriate delegation rules, and the legal mandate to exhaust all less restrictive alternatives first.

Key Concept

Prioritizing least restrictive de-escalation techniques, milieu safety, and appropriate nursing delegation during acute behavioral crises.
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Topics

Behavioral Interventions

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