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Zorluk: ZorCrisis Intervention

A client on a secure dementia care unit becomes acutely agitated during the evening shift, attempting to strike staff members with a hairbrush while insisting they need to "go catch the school bus." Which intervention should the practical nurse (PN) implement first?

  1. Increase the space between the nurse and the client while calmly asking the client to describe where the bus is going.Cevap
  2. B
    Remind the client of their current age and location to help reorient them to reality.
  3. C
    Ask the client, "Why do you feel you need to catch the school bus at this time of night?"
  4. D
    Escort the client to their room and close the door to reduce environmental stimulation.

Cevap

The priority action is to maintain physical safety by increasing distance, followed by using validation therapy to enter the client's reality and de-escalate the emotional distress.
The correct answer correctly addresses both immediate priorities in this specific crisis: physical safety and therapeutic communication. By increasing the space between the nurse and the client, the nurse prevents physical injury from the hairbrush. By asking the client to describe where the bus is going, the nurse employs validation therapy. In clients with dementia, entering their reality rather than challenging it is the most effective way to decrease panic, build trust, and de-escalate aggressive behaviors.

Adım Adım Çözüm

1
Assess the immediate physical threat to staff and the client in the environment.
The client is attempting to strike staff with an object, requiring an immediate adjustment of physical proximity.
Ensuring physical safety is the absolute first priority in any behavioral crisis before verbal interventions begin.
2
Determine the underlying etiology of the agitation and the client's cognitive capacity.
The client is experiencing an altered reality related to dementia and cannot process logical reasoning.
De-escalation interventions must be tailored to the client's specific cognitive state and ability to comprehend.
3
Select a de-escalation technique that mitigates the emotional distress without provoking further aggression.
Validation therapy is chosen to acknowledge the client's feelings and current reality about the bus.
Challenging the reality of an actively agitated client with dementia will escalate aggressive behaviors, whereas validation fosters trust and calm.

Anahtar Kavram

Crisis De-escalation and Safety in Cognitive Impairment
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Konular

Crisis Intervention

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