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Zorluk: OrtaSubstance Use and Other Disorders

A newly admitted client on a dual-diagnosis unit is experiencing acute sensory alterations following recent illicit substance ingestion. The client abruptly backs into a corner, tightly clenches both fists, and shouts, "The snakes are coming out of the air vents to bite me!" Which action should the practical nurse take first?

  1. Maintain a safe physical distance and call for the facility's designated crisis response personnel.Cevap
  2. B
    Reassure the client by logically explaining that there are no snakes present in the facility vents.
  3. C
    Ask the client why they feel threatened by the vents during this specific moment.
  4. D
    Obtain soft limb restraints to apply immediately for the prevention of self-harm.

Cevap

Maintain a safe physical distance and call for the facility's designated crisis response personnel.
The primary nursing priority during an active behavioral crisis with escalating agitation is to ensure the safety of the client, staff, and others. Maintaining a safe physical distance prevents sudden injury from an unpredictable client, while activating the crisis response team ensures adequate personnel are present to manage the situation safely.

Adım Adım Çözüm

1
Analyze the client's behavior and physiological cues.
The client is experiencing a substance-induced hallucination, clenching fists, and backing into a corner.
Identifying signs of escalating agitation and potential violence is essential for determining the appropriate intervention.
2
Determine the priority need based on the nursing process.
The immediate priority is the physical safety of the client and the nursing staff.
When a client is in an active behavioral crisis, environmental and personal safety supersedes therapeutic communication or routine assessment.
3
Select the most appropriate, least restrictive safety intervention.
Maintaining distance and calling for help is chosen over logical reasoning or immediate restraints.
Distance protects the nurse from sudden physical outbursts, and additional trained staff can help safely manage the situation without prematurely resorting to physical restraints.

Anahtar Kavram

De-escalation and safety management for substance-induced acute agitation.
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Konular

Substance Use and Other Disorders

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