Examkin

Soru

Zorluk: OrtaBehavioral Interventions

An adolescent client admitted to a general pediatric unit for the management of diabetic ketoacidosis becomes increasingly upset after being informed that friends cannot visit after visiting hours. The client yells profanities, throws a plastic water pitcher against the wall, and demands to leave the hospital immediately. What is the priority nursing action?

  1. Maintain a non-confrontational body posture, stand at an angle to the client, and use a calm tone of voice.Cevap
  2. B
    Request a prescription for a rapid-acting intramuscular sedative from the healthcare provider.
  3. C
    Assign an unlicensed assistive personnel to remain in the room and closely observe the client.
  4. D
    Inform the client that this behavior is unacceptable and will result in the loss of unit privileges.

Cevap

The correct priority action is to maintain a non-confrontational body posture, stand at an angle to the client, and use a calm tone of voice.
During an acute behavioral escalation, the initial priority is safety and verbal de-escalation. Standing at an angle (rather than face-to-face) appears less threatening, reduces the perception of confrontation, and maintains a safer physical position for the nurse. Using a calm, even tone of voice and a relaxed posture can help lower the client's anxiety and prevent further escalation. These non-pharmacological, least-restrictive interventions must be attempted first.

Adım Adım Çözüm

1
Assess the client's current behavioral state and the immediate environment.
The client is demonstrating acute agitation and aggressive behavior (throwing objects, yelling).
Recognizing the level of escalation dictates the appropriate intervention tier.
2
Determine the most appropriate intervention based on the principle of least restrictive alternative.
Verbal and non-verbal de-escalation techniques must be utilized before moving to physical or chemical interventions.
Nursing standards require exhausting less restrictive measures before utilizing restraints.
3
Implement safe non-verbal and verbal de-escalation techniques.
The nurse adopts a relaxed posture, stands at an angle to avoid appearing confrontational, and speaks calmly.
These specific techniques lower the client's defensiveness, model calm behavior, and ensure the nurse's physical safety by keeping an exit route accessible.

Anahtar Kavram

De-escalation and Least Restrictive Behavioral Interventions
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Konular

Behavioral Interventions

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