While working the evening shift at a behavioral health facility, the registered nurse observes an individual in the manic phase of bipolar disorder wandering into the bedrooms of peers, taking their personal items, and singing loudly. Other individuals on the unit are expressing visible anger, and one peer explicitly threatens to physically retaliate against the hyperactive client. Which action should the nurse implement first to restore safety and maintain a therapeutic environment?
- Escort the hyperactive client to a low-stimulus area and engage them in a simple, solitary activityAnswer
- BDelegate the unlicensed assistive personnel to monitor the hallway and prevent the client from entering other bedrooms
- CTell the hyperactive client that they will be placed in the seclusion room if they do not stop taking peers' belongings
- DAdminister a prescribed as-needed intramuscular antipsychotic medication to quickly decrease the client's hyperactivity
Answer
Escort the hyperactive client to a low-stimulus area and engage them in a simple, solitary activity.
The correct answer is to escort the hyperactive client to a low-stimulus area because the immediate priority is separating the clients to prevent physical injury. Clients experiencing acute mania are highly distractible and require a reduction in environmental stimuli. Redirecting the client to a solitary activity manages their excess energy safely, diffuses the tension in the milieu, and utilizes the least restrictive intervention available.
Step-by-Step Solution
Key Concept
In a psychiatric emergency involving an escalating milieu and threats of violence, the nurse's priority is to ensure physical safety by separating clients and utilizing the least restrictive environmental interventions (such as decreasing stimuli and redirection) before considering chemical or physical restraints.