A practical nurse (PN) in a long-term care facility observes a client with moderate dementia becoming increasingly agitated, pacing the hallway, and shouting at other residents. In what order should the PN perform the following interventions? (Arrange from first action to last action)
- 1Direct other residents away from the immediate area.
- 2Maintain a safe physical distance and speak to the client in a calm, low voice.
- 3Acknowledge the client's feelings of distress using simple, direct statements.
- 4Offer a familiar, calming distraction such as folding towels or looking at a magazine.
- 5Document the behavioral incident, the interventions implemented, and the client's response.
Cevap
The correct sequence of actions prioritizes immediate milieu safety, followed by personal safety and verbal de-escalation, emotional validation, behavioral redirection, and finally, documentation.
The correct order follows the nursing process and safety priorities for behavioral emergencies. Immediate safety of the milieu is paramount, so moving bystanders is always the first action. Next, the nurse must establish a safe connection using a calm voice and safe physical distance. Once contact is made, validating feelings helps to de-escalate the emotional state. After the client is calmer, redirection to a constructive activity provides an outlet for their energy. Finally, documentation is completed once the situation is fully resolved.
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Anahtar Kavram
Crisis De-escalation and Milieu Safety Prioritization