A practical nurse (PN) is working in an outpatient community health clinic. A client waiting for an appointment suddenly becomes highly agitated, clenching their fists, pacing the hallway, and yelling loudly. Arrange the following nursing actions in the priority order the PN should implement them. (Place the first action at the top and the last action at the bottom.)
- 1Maintain a safe physical distance and ensure a clear exit path.
- 2Direct bystanders and other clients away from the immediate area.
- 3Address the client using short, simple sentences in a calm tone.
- 4Report the client's escalating behavior to the supervising registered nurse (RN).
Cevap
The correct sequence is to first ensure personal safety (distance and exit), then secure the safety of others (directing bystanders away), followed by attempting verbal de-escalation, and finally reporting the event to the supervising RN.
In a crisis or escalating behavioral situation, safety principles dictate that the nurse must first ensure their own safety by maintaining a safe distance and an unobstructed exit. If the nurse is injured, they cannot help the client or others. Next, the nurse must protect bystanders, which also removes the 'audience' and decreases stimulation for the agitated client. Once the environment is physically secure, the nurse can safely attempt verbal de-escalation techniques using a calm, non-confrontational approach. Finally, the practical nurse must report the situation to the supervising RN to collaborate on further interventions, such as activating security protocols or evaluating the need for medication.
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Anahtar Kavram
Prioritization of care during a behavioral crisis requires ensuring personal safety first, followed by the safety of others, initiating verbal de-escalation, and then collaborating with the healthcare team.