Examkin

Soru

Zorluk: ZorBehavioral Interventions

Following a multidisciplinary care conference, a 15-year-old client on a pediatric mental health unit is informed that their anticipated discharge has been postponed. The client abruptly begins screaming, forcefully kicks a chair, and starts hurling paperback books across the shared recreation room where several other adolescents are gathered. Which immediate action should the practical nurse implement?

  1. Instruct the remaining adolescents to quickly exit the recreation room while keeping a safe spatial boundary from the escalating client.Cevap
  2. B
    Attempt to calmly explain to the client that destroying property will only cause further delays to their treatment progress.
  3. C
    Direct assistive personnel to physically grasp the client's arms to prevent them from throwing additional objects.
  4. D
    Ask the client, 'Why are you reacting this way when the healthcare team is only trying to ensure you are safe to go home?'

Cevap

Instruct the remaining adolescents to quickly exit the recreation room while keeping a safe spatial boundary from the escalating client.
The correct answer prioritizes immediate environmental and milieu safety. During an active, acute behavioral escalation where a client is acting out physically (throwing objects), the primary responsibility of the nurse is to protect everyone in the vicinity. Evacuating the other adolescents removes the immediate risk of physical injury and decreases the audience, which can help lower the overall stimulation in the room. Keeping a safe spatial boundary protects the nurse from being struck.

Adım Adım Çözüm

1
Assess the immediate environment for physical safety threats during the client's active behavioral escalation.
The nurse identifies that the client throwing solid objects poses an imminent physical danger to the other peers currently in the recreation room.
Safety of the entire milieu is always the primary concern during an acute behavioral crisis.
2
Prioritize interventions based on the hierarchy of safety and least restrictive measures.
Clearing the environment protects bystanders and reduces audience-induced stimulation without prematurely applying physical restrictive measures to the agitated client.
Protecting others must occur before attempting verbal de-escalation of a highly volatile individual.
3
Implement the priority action while observing personal safety.
The nurse maintains a safe spatial boundary to avoid personal injury while successfully directing the other clients to evacuate.
Nurses must maintain their own physical safety to effectively manage the crisis.

Anahtar Kavram

During an acute behavioral escalation involving violence or throwing objects, the nurse's immediate priority is the physical safety of all individuals in the milieu, achieved by clearing the area and maintaining a safe distance before attempting de-escalation.
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Behavioral Interventions

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