A practical nurse (PN) is working in the dayroom of a mental health unit. A client with post-traumatic stress disorder (PTSD) experiences a sudden flashback, becomes highly agitated, and throws a chair. Arrange the PN's actions in the correct priority order. All options must be used.
- 1Direct other clients and visitors to evacuate the dayroom.
- 2Maintain a safe physical distance while keeping an unobstructed exit path.
- 3Speak in a calm, low voice to orient the client to their current surroundings.
- 4Offer the client the choice to move to a quiet, low-stimulation area.
- 5Document the specific trigger, the client's behavior, and the interventions used.
Cevap
The correct priority order is to first secure the milieu by evacuating bystanders, then ensure personal safety by maintaining distance, followed by verbal de-escalation, offering a quiet environment, and finally documenting the event.
In any psychiatric emergency involving violent or destructive behavior, the nurse's first action is to secure the milieu by removing bystanders to prevent injury. The second step is to ensure personal safety by maintaining a safe distance and an open exit. Once the environment and nurse are safe, verbal de-escalation can begin by speaking calmly and orienting the client. Offering a quiet space is the next appropriate step to reduce stimulation. Finally, documentation is completed after the crisis has resolved.
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Anahtar Kavram
Crisis De-escalation and Milieu Safety