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Zorluk: ZorSubstance Use and Other Disorders

During rounds on the behavioral health unit, a client recovering from amphetamine toxicity suddenly backs into the corner of the dayroom. The client is heavily diaphoretic, glaring at the ceiling, and shouting, "The drones are dropping poison on me!" Which action is the priority for the nurse to implement?

  1. A
    Explain to the client that the hospital is a secure facility and no drones are present.
  2. B
    Walk directly toward the client to verbally de-escalate the situation using a soft voice.
  3. C
    Contact the healthcare provider immediately to obtain a prescription for mechanical restraints.
  4. Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.Cevap

Cevap

Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.
The priority when managing a client experiencing stimulant-induced psychosis and paranoia is establishing physical safety. By maintaining a safe distance and ensuring an unobstructed exit, the nurse protects themselves and prevents the client from feeling trapped, which reduces the immediate risk of violence.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is exhibiting symptoms of severe stimulant-induced psychosis, including paranoia, visual hallucinations, and backing into a corner.
Recognizing the signs of a psychotic break allows the nurse to anticipate unpredictable or defensive behavior.
2
Evaluate the priority of care based on the scenario.
Immediate physical safety for both the client and the nursing staff is the absolute highest priority.
A cornered, terrified client experiencing hallucinations may resort to violence in an attempt to protect themselves from perceived threats.
3
Select the safest initial nursing intervention.
The nurse must secure the environment by keeping a safe physical distance and ensuring an unblocked escape route.
This strategy de-escalates the immediate environmental tension and provides the nurse with a safe way out if the client becomes physically aggressive.

Anahtar Kavram

Crisis Intervention and Safety in Substance-Induced Psychosis
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Konular

Substance Use and Other Disorders

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