A client with acute delirium and severe agitation in the emergency department is shouting at staff, refusing care, and attempting to climb over the bed rails. Which interventions should the nurse implement as the initial approach to manage this behavioral escalation? Select all that apply.
- Decrease environmental stimuli by dimming the lights and turning off the television.Answer
- Approach the client from the side rather than moving directly face-to-face.Answer
- Speak in a calm, low-pitched voice using short, simple sentences.Answer
- DQuestion the client regarding their behavior by asking, 'Why are you acting this way when we are just trying to help?'
- EDirect the unlicensed assistive personnel (UAP) to evaluate the client's current cognitive orientation.
- FAdminister the prescribed PRN chemical restraint immediately to protect the safety of the staff.
Answer
The correct interventions are to decrease environmental stimuli, approach the client from the side, and speak in a calm, low-pitched voice using short, simple sentences.
Initial management of an acute behavioral crisis requires implementing the least restrictive interventions to de-escalate the client. Decreasing environmental noise and lighting reduces sensory overload, which is a major contributor to delirium and agitation. Approaching the client from the side is perceived as far less threatening than a direct frontal approach, helping to respect their personal space and reduce feelings of being trapped. Using a calm, low-pitched voice with short, direct statements is much easier for an agitated or confused mind to process, promoting a calming environment.
Step-by-Step Solution
Key Concept
De-escalation Techniques and Least Restrictive Interventions
Estimated Time:1m 30s