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Zorluk: OrtaBehavioral Interventions

A client experiencing an acute manic episode is pacing rapidly in the dayroom, speaking loudly, and beginning to invade the personal space of other clients. The nurse must intervene to prevent further escalation. Arrange the following nursing interventions in order from least restrictive to most restrictive.

  1. 1Speak to the client in a calm, clear voice to identify their immediate needs.
  2. 2Direct the client to a quiet, low-stimulus area away from peers.
  3. 3Offer a prescribed oral as-needed (PRN) dose of an anxiolytic.
  4. 4Administer a prescribed intramuscular (IM) antipsychotic medication.
  5. 5Initiate physical holding techniques with the psychiatric emergency response team.

Cevap

The correct sequence from least restrictive to most restrictive is: Verbal de-escalation, environmental modification, voluntary oral medication, involuntary intramuscular medication, and finally physical holding techniques.
The principle of the least restrictive environment mandates that nurses must attempt interventions that allow the client the highest degree of autonomy before escalating to more restrictive measures. The correct sequence naturally progresses from simple communication, to changing the environment, to offering voluntary choices (oral medication), to forcing a chemical intervention (IM medication), and finally resorting to physical force.

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1
Identify the guiding principle for behavioral interventions.
The principle of the least restrictive environment is established as the priority.
Client rights mandate that autonomy and freedom of movement must be preserved as much as safely possible.
2
Select the initial, least invasive intervention.
Speaking to the client in a calm, clear voice is placed first.
Verbal communication requires no restriction of movement or chemical alteration.
3
Determine the next step if verbal de-escalation is insufficient.
Directing the client to a quiet area is placed second.
Environmental modification reduces stimuli without forcing medication or using physical restraints.
4
Choose the least restrictive medical intervention.
Offering an oral PRN medication is placed third.
Offering oral medication preserves the client's choice and relies on voluntary compliance.
5
Identify the intervention required if voluntary compliance fails.
Administering an IM antipsychotic is placed fourth.
An injection bypasses client consent and acts as a chemical restraint, which is highly restrictive.
6
Select the absolute last resort intervention.
Initiating physical holding techniques is placed last.
Physical force carries the highest risk of trauma and physical injury, making it the most restrictive option.

Anahtar Kavram

Behavioral Interventions: Least Restrictive Environment
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Konular

Behavioral Interventions

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