A nurse on a locked behavioral health unit is caring for an adult client. The client approaches the nurses' station with a raised voice, tightly clenched fists, and demands immediate access to a restricted personal item. When the nurse explains the unit safety policy, the client becomes abruptly escalated, begins aggressively striking the reinforced glass, and shouts threats at the staff. Which of the following initial interventions should the nurse implement? Select all that apply.
- Instruct other clients in the immediate vicinity to relocate to the dayroom.Answer
- Maintain a relaxed body posture with hands open and visible while standing slightly at an angle to the client.Answer
- Offer the client a concrete choice between retreating to a quiet area or taking an oral PRN antianxiety medication.Answer
- DTell the client, 'I know you are upset, but everything will be completely fine once you take a deep breath.'
- EDelegate the task of monitoring the client's escalation triggers and emotional status to the unlicensed assistive personnel (UAP).
- FInitiate the facility protocol for physical restraints to prevent imminent property destruction and self-harm.
Answer
The correct interventions are to relocate other clients to the dayroom, maintain a relaxed and angled body posture, and offer the client a concrete choice of safe alternatives.
The appropriate initial actions for an aggressively escalating client focus on milieu safety, non-threatening engagement, and promoting client autonomy. Relocating bystanders secures the environment. Maintaining an angled, relaxed posture visually communicates that the nurse is not a threat. Finally, offering concrete, safe choices provides the client with a way to regain self-control without resorting to restrictive measures.
Step-by-Step Solution
Key Concept
Behavioral Crisis De-escalation and Least Restrictive Interventions