A practical nurse (PN) is in the mental health unit dayroom when a client with bipolar disorder in a manic phase suddenly becomes highly agitated, pacing aggressively, and shouting at peers. Arrange the following nursing actions in the order of priority, from first to last.
- 1Maintain a safe physical distance and ensure a clear personal exit path.
- 2Direct other clients to calmly leave the dayroom.
- 3Attempt verbal de-escalation using a calm, firm, and non-confrontational voice.
- 4Offer the client a prescribed PRN oral antianxiety medication.
Cevap
The correct priority is to first secure personal safety, then protect bystanders, followed by attempting verbal de-escalation, and finally offering pharmacological interventions.
In any psychiatric emergency involving behavioral escalation, the absolute first priority is safety. The nurse must secure their own safety (ensuring an exit), followed closely by the safety of the milieu (removing other clients). Once the environment is secure, the nurse applies interventions based on the principle of least restrictive means, starting with verbal de-escalation and progressing to pharmacological interventions if behavioral strategies are ineffective.
Adım Adım Çözüm
Anahtar Kavram
Crisis De-escalation and Least Restrictive Interventions