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Zorluk: OrtaBehavioral Interventions

While working in an acute mental health facility, a practical nurse observes a client with schizophrenia pacing the main corridor. The client has clenched fists, is breathing rapidly, and is glaring at a nearby staff member. Which action should the nurse take first?

  1. Maintain a safe distance, use a calm voice, and invite the client to walk to a quieter area.Cevap
  2. B
    Step directly in front of the client to block their path and firmly instruct them to stop pacing.
  3. C
    Immediately prepare and administer a prescribed as-needed intramuscular sedative.
  4. D
    Ask the client to explain exactly why they are feeling so angry and aggressive today.

Cevap

The nurse should prioritize safety and least-restrictive interventions by maintaining a safe distance and using verbal de-escalation to guide the client to a lower-stimulus environment.
The client is demonstrating early signs of agitation and potential escalation. The priority action is to employ verbal de-escalation techniques while ensuring physical safety. Maintaining a safe distance prevents the client from feeling trapped, and offering a quieter area reduces environmental stimulation. This approach aligns with the principle of using the least-restrictive intervention first.

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1
Assess the client's current behavioral state based on physical cues.
The nurse identifies that pacing, clenched fists, and glaring indicate escalating agitation and a potential behavioral crisis.
Early recognition of agitation allows for prompt intervention before physical violence occurs.
2
Determine the safest physical positioning for the nurse.
The nurse decides to maintain a safe distance rather than physically confronting or blocking the client.
Invading personal space or attempting to physically block an agitated client increases the immediate risk of assault.
3
Select the appropriate de-escalation technique following the least-restrictive hierarchy.
The nurse uses a calm, non-confrontational voice to invite the client to a quieter area.
Verbal de-escalation and environmental modification (moving to a quieter area) are the least restrictive initial interventions for an escalating client.

Anahtar Kavram

Behavioral Interventions and De-escalation
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Konular

Behavioral Interventions

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