A practical nurse (PN) is working in a behavioral health facility. A client with acute methamphetamine intoxication is pacing the hallway, shouting aggressively at unseen individuals, and clenching their fists. Arrange the following nursing actions in the correct sequence from highest to lowest priority.
- 1Ensure a safe physical distance between the nurse and the client.
- 2Alert additional facility staff to respond to the area.
- 3Direct other clients in the hallway to move to a safe location.
- 4Address the client using a calm, nonconfrontational tone to encourage de-escalation.
- 5Assist the registered nurse (RN) in preparing prescribed PRN medication for agitation.
Cevap
The correct sequence is to first ensure personal safety, then call for backup, protect bystanders, attempt verbal de-escalation, and finally assist with chemical interventions.
In any situation involving acute aggression and substance-induced psychosis, the hierarchy of response focuses on safety and the principle of least restrictive intervention. The nurse must first ensure personal safety by maintaining distance, as an injured nurse cannot provide care. Next, calling for backup ensures sufficient personnel are present to manage potential violence safely. The third step is protecting bystanders by clearing the area. Once the environment is secure, the nurse attempts verbal de-escalation as the least restrictive direct intervention. Finally, if verbal methods fail to reduce the danger, assisting the registered nurse with prescribed medications serves as the appropriate next step for chemical restraint.
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Anahtar Kavram
Prioritization of safety and least restrictive interventions in acute substance-induced psychosis