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Question

Difficulty: MediumBehavioral Interventions

A client admitted to an oncology unit is found vigorously pacing the main corridor. The client is clenching their jaw, breathing heavily, and loudly accusing a dietary aide of intentionally withholding their breakfast. What is the priority nursing action to manage this behavior safely?

  1. Acknowledge the client's distress and offer a choice of returning to their room or going to the consultation lounge to discuss the issue.Answer
  2. B
    Stand squarely in front of the client to establish authority and firmly instruct them to lower their voice.
  3. C
    Direct an unlicensed assistive personnel to closely shadow the client in the hallway to ensure safety.
  4. D
    Contact the facility's security response team immediately to prevent a physical altercation with the dietary aide.

Answer

The priority action is to acknowledge the client's distress and offer them a choice of locations to talk, effectively de-escalating the situation using the least restrictive approach.
The correct action applies core de-escalation techniques: validating the client's emotional state, offering autonomy through choices, and moving the client away from the triggering stimulus (the dietary aide and the busy hallway) to a quieter environment. This represents the least restrictive, most therapeutic initial approach.

Step-by-Step Solution

1
Assess the client's behavior and level of escalation.
The client is highly anxious and verbally aggressive, but has not yet committed physical violence.
Accurate assessment determines whether verbal de-escalation is appropriate or if immediate physical safety measures are required.
2
Apply the principle of least restrictive intervention.
Identify verbal de-escalation as the first-line approach for a client who is agitated but not physically violent.
Nurses are required to use the least restrictive measures possible to manage behavioral crises before escalating to security, restraints, or seclusion.
3
Select the specific de-escalation techniques.
Choose to validate the client's feelings, adopt a non-threatening posture, and offer choices to move to a less stimulating environment.
Offering choices empowers the client and reduces feelings of helplessness, which are common drivers of aggressive behavior.

Key Concept

Verbal De-escalation and Least Restrictive Interventions
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Topics

Behavioral Interventions

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