A nurse is caring for a client on a medical-surgical unit who suddenly begins pacing rapidly, clenching their fists, and glaring at staff members. The client is visibly agitated and their behavior is escalating. Arrange the following nursing interventions in the order they should be implemented, prioritizing from the least restrictive approach to the most restrictive.
- 1Direct other clients and visitors in the immediate area to return to their rooms.
- 2Approach the client from an angle, maintaining a safe distance, and use a calm voice to ask what is wrong.
- 3Offer the client a prescribed as-needed (PRN) oral antianxiety medication.
- 4Activate the facility's crisis intervention team to provide a show of support.
- 5Administer an emergency intramuscular sedative medication with the assistance of the crisis team.
Answer
The correct sequence from least to most restrictive is: clear the area of bystanders, attempt verbal de-escalation, offer voluntary oral medication, activate the crisis team for a show of support, and finally administer involuntary emergency medication.
The principle of least restrictive intervention mandates that nurses manage behavioral escalation through a specific hierarchy. The nurse must first ensure environmental safety (clearing the area) and utilize verbal techniques. If unsuccessful, the progression moves to voluntary oral medications, followed by a team response (show of support), and utilizes involuntary chemical restraints (IM medication) only as a final measure to prevent imminent harm.
Step-by-Step Solution
Key Concept
Hierarchy of behavioral interventions from least to most restrictive