A practical nurse (PN) is working on an inpatient behavioral health unit. A client suddenly becomes agitated, pacing rapidly near the common area, breathing heavily, and clenching their fists. Arrange the following PN actions in the correct order of priority, from first to last.
- 1Maintain a safe physical distance and ensure an unobstructed path to the unit exit.
- 2Speak to the client using a calm, low-pitched, and non-threatening tone of voice.
- 3Offer the client the option to relocate to a quiet, low-stimulus environment.
- 4Document the client's specific behaviors and the outcomes of the nursing interventions.
Cevap
The priority sequence is to first ensure personal safety, then initiate verbal de-escalation, followed by offering a least-restrictive alternative space, and finally documenting the event.
According to the principles of psychiatric nursing and crisis intervention, the absolute first priority is safety. The PN must secure their own safety by maintaining distance and an exit path. Once safe, the PN uses therapeutic communication to de-escalate the situation verbally. Next, the PN applies the principle of the least restrictive environment by offering a quiet space to reduce stimulation. Finally, after the situation is stabilized, the PN documents the objective data and outcomes.
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Anahtar Kavram
Crisis De-escalation and Priority of Care