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Zorluk: OrtaBehavioral Interventions

A client admitted to an orthopedic unit for a fractured tibia is exhibiting signs of escalating agitation. The client is pacing the room, speaking loudly, and aggressively pulling at their peripheral intravenous (IV) catheter. Arrange the following nursing interventions in the order they should be implemented, from the least restrictive to the most restrictive.

  1. 1Attempt verbal de-escalation by speaking in a calm, non-confrontational tone.
  2. 2Decrease environmental stimulation by turning off the television and dimming the room lights.
  3. 3Offer the client a prescribed as-needed (PRN) oral antianxiety medication.
  4. 4Administer a prescribed as-needed (PRN) intramuscular (IM) sedative.
  5. 5Apply physical restraints to prevent the client from dislodging the IV catheter.

Cevap

The correct sequence follows the least restrictive alternative doctrine: attempt verbal de-escalation first, followed by decreasing environmental stimuli, offering voluntary oral medication, administering an intramuscular chemical restraint, and finally applying physical restraints as an absolute last resort.
The principle of least restrictive intervention mandates that nurses must exhaust all verbal, environmental, and voluntary pharmacological options before resorting to involuntary chemical or physical restraints. This sequential approach ensures client safety while preserving autonomy, dignity, and legal rights.

Adım Adım Çözüm

1
Assess the client's behavioral state and immediate safety risks.
Identifies escalating agitation without an immediate, life-threatening emergency.
Establishes a baseline to determine the appropriate starting point on the intervention hierarchy.
2
Implement non-pharmacological, non-physical interventions.
Uses verbal de-escalation and environmental modification.
Adheres to the legal and ethical requirement to exhaust the least restrictive, non-invasive measures first.
3
Utilize pharmacological interventions starting with the least invasive route.
Offers oral medications first, followed by IM medications only if necessary.
Chemical interventions are considered more restrictive than verbal or environmental ones; the oral route is less invasive than the intramuscular route.
4
Implement physical restraints only if all previous steps fail.
Applies soft extremity restraints to protect the IV line.
Physical restraints carry the highest risk of injury, loss of dignity, and psychological trauma, making them the ultimate last resort.

Anahtar Kavram

Least Restrictive Intervention Hierarchy
Tahmini Süre:1m 0s
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Konular

Behavioral Interventions

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