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Difficulty: HardMental Health Concepts

A client diagnosed with paranoid schizophrenia is watching television in the psychiatric unit dayroom. Suddenly, the client stands up, points at the screen, and shouts, "The broadcaster is sending the activation signals! They are coming to take me away!" The client begins pacing rapidly, clenching their fists, and breathing heavily. Which of the following is the most appropriate initial nursing action?

  1. Maintain a safe distance, speak in a calm voice, and state, "You look very frightened. Let's walk to the quiet room together."Answer
  2. B
    Turn off the television and firmly state, "The television is just broadcasting the news. It is not sending you any signals."
  3. C
    Approach the client to assess vital signs to rule out a physiological cause for the sudden agitation.
  4. D
    Prepare to administer the client's prescribed PRN intramuscular antipsychotic medication.

Answer

Acknowledge the client's underlying emotion (fear) and offer to move to an environment with decreased stimulation.
The correct action utilizes therapeutic communication by acknowledging the client's underlying emotion (fear) without validating the content of the delusion ("activation signals"). Offering to move to the quiet room decreases the environmental stimuli that are exacerbating the client's paranoia, and it represents the least restrictive, safest initial intervention for de-escalation.

Step-by-Step Solution

1
Assess the situation for safety and determine the client's current behavioral state.
The client is experiencing a delusion and is exhibiting signs of escalating anxiety and paranoia (pacing, clenched fists), but has not committed an act of violence.
Accurate assessment of the escalation level dictates the appropriate restrictiveness of the nursing intervention.
2
Select an intervention that addresses the emotional theme without reinforcing the psychotic content, while also modifying the environment.
The nurse validates the client's fear and gently removes them from the triggering stimulus (the television and the busy milieu).
This approach builds trust, promotes safety, and adheres strictly to the principle of using the least restrictive intervention first.

Key Concept

Therapeutic De-escalation and Milieu Management
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Topics

Mental Health Concepts

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