Examkin

Soru

Zorluk: OrtaBehavioral Interventions

Following a visit from family members, a client diagnosed with paranoid schizophrenia begins pacing the perimeter of the dayroom, breathing heavily, and aggressively pointing at the ceiling security cameras. Which actions should the practical nurse take to manage this behavior? Select all that apply.

  1. Clear the dayroom of other clients and unnecessary personnel.Cevap
  2. B
    Stand directly in front of the primary exit to contain the client in the room.
  3. Maintain a slightly angled body posture with hands relaxed and visible.Cevap
  4. Communicate using a soft tone and brief, direct sentences.Cevap
  5. E
    Reassure the client by stating that the security cameras have been temporarily disabled.
  6. F
    Apply physical restraints immediately to prevent the client from damaging the cameras.

Cevap

The correct actions are to clear the dayroom of other clients, maintain a slightly angled body posture with visible hands, and communicate using a soft tone with brief, direct sentences.
When a client exhibits escalating agitation, the primary goals are ensuring safety and using the least restrictive methods to calm the individual. Clearing the room protects other clients and reduces sensory input. Standing at an angle with visible hands is a non-threatening posture that respects personal space without blocking escape routes. Using a soft tone and short, simple sentences is crucial because high anxiety severely impairs cognitive processing.

Adım Adım Çözüm

1
Assess the client's behavior and the immediate environment.
The client is exhibiting signs of escalating agitation (pacing, heavy breathing, aggressive pointing) driven by paranoia regarding the security cameras.
Recognizing the escalation phase alerts the nurse to initiate immediate non-pharmacological de-escalation protocols.
2
Prioritize milieu safety and reduce environmental stimulation.
Other clients and personnel are removed from the dayroom.
This protects bystanders from potential harm and removes excess sensory input that can worsen the agitated client's paranoia.
3
Utilize safe, non-threatening therapeutic de-escalation techniques.
The nurse uses an angled posture, keeps hands visible, and speaks softly in short, clear sentences.
These physical and verbal actions prevent the client from feeling trapped while accommodating their reduced ability to process complex information during a crisis.

Anahtar Kavram

During behavioral escalation, the nurse must prioritize immediate safety (for the client and bystanders) and utilize least-restrictive de-escalation techniques such as decreasing environmental stimuli and using non-threatening communication.
Bu soruyu puanla

Konular

Behavioral Interventions

Bu konudan daha fazla soru