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Zorluk: KolayMental Health Concepts

An agitated client on the psychiatric acute care unit begins pacing rapidly, shouting at staff, and clenching their fists. To ensure safety while adhering to the principle of least restrictive intervention, arrange the following nursing actions in the order they should be implemented, starting with the least restrictive action first.

  1. 1Attempt verbal de-escalation and encourage the client to move to a quiet area.
  2. 2Offer a prescribed oral as-needed (PRN) antianxiety medication.
  3. 3Administer a prescribed intramuscular (IM) antipsychotic medication.
  4. 4Place the client in a locked seclusion room.
  5. 5Apply mechanical physical restraints to the client's limbs.

Cevap

The correct sequence from least to most restrictive is: attempting verbal de-escalation, offering an oral medication, administering an intramuscular medication, placing the client in seclusion, and finally, applying mechanical physical restraints.
Psychiatric nursing standards require interventions to progress from the least restrictive to the most restrictive to ensure safety while preserving client rights. Verbal communication is the least invasive. If that fails, voluntary oral medications are offered. If the client remains a danger and refuses oral meds, involuntary IM medications (chemical restraints) are used. If the client is still a severe danger, seclusion is utilized. Mechanical physical restraints are the absolute last resort when all other measures have failed.

Adım Adım Çözüm

1
Identify the foundational principle of psychiatric emergency intervention.
The nurse must always begin with the least restrictive intervention to protect client autonomy and rights.
Ethical and legal standards mandate that clients be treated in the least restrictive environment possible.
2
Evaluate verbal and environmental modifications.
Verbal de-escalation and moving the client to a quiet area are selected as the first action.
These techniques require no physical force or medication and empower the client to regulate their own behavior.
3
Differentiate between pharmacological interventions.
Oral PRN medication is prioritized over intramuscular (IM) medication.
Oral administration allows for voluntary compliance and is less invasive and traumatic than an IM injection.
4
Determine the hierarchy of physical containment.
Seclusion is implemented before mechanical physical restraints.
Seclusion allows the client to move freely within a room, whereas mechanical restraints completely immobilize the client's limbs, making restraints the most extreme and restrictive measure.

Anahtar Kavram

Principle of Least Restrictive Intervention
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Mental Health Concepts

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