A client at a community health clinic suddenly becomes severely agitated, throwing magazines across the waiting room and shouting, 'Everyone here is trying to trick me!' The client clenches their fists and glares at a practical nurse who is standing nearby. Which action should the nurse take first?
- Ensure a clear exit path and direct other individuals away from the immediate area.Cevap
- BSlowly step toward the client to logically explain that the staff is there to help.
- CAsk the client why they feel they are being tricked by the clinic staff.
- DInitiate the application of physical restraints to prevent the client from causing injury.
Cevap
Ensure a clear exit path and direct other individuals away from the immediate area.
During an active behavioral crisis where a client is demonstrating physical aggression (throwing objects, clenching fists), the first and most critical action is to ensure safety. By maintaining a safe distance, ensuring a clear exit path, and removing bystanders, the nurse protects themselves and others while simultaneously reducing the environmental stimulation that may be contributing to the client's agitation.
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Crisis Intervention: Prioritizing Safety and De-escalation