Behavioral Interventions

A nurse is caring for a client on a medical-surgical unit who suddenly begins pacing rapidly, clenching their fists, and glaring at staff members. The client is visibly agitated and their behavior is escalating. Arrange the following nursing interventions in the order they should be implemented, prioritizing from the least restrictive approach to the most restrictive.

A client is admitted to the inpatient psychiatric unit with major depressive disorder and active suicidal ideation. After five days of refusing meals, isolating in their room, and avoiding staff interactions, the client suddenly emerges into the dayroom smiling. The client hands a cherished watch to a peer and states, "The heavy cloud has finally lifted. I know exactly what I have to do now, and everything will be at peace." Which of the following is the priority nursing action?

A client with a history of aggressive behavior is pacing rapidly in the day room, clenching their fists, and muttering angrily to themselves. The nurse needs to intervene to prevent an escalation of violence. Arrange the following behavioral interventions in chronological order from the least restrictive to the most restrictive approach.

A nurse is managing care for a client admitted with borderline personality disorder, severe anxiety, and a recent history of superficial self-inflicted lacerations. Over the past 48 hours, the client has been highly agitated, frequently requesting PRN lorazepam, and repeatedly attempting to manipulate unit rules. Today, the client suddenly stops pacing, appears completely relaxed, and hands a favorite jacket to another client, stating, "I finally made a decision about how to solve my problems. I won't be bothering the staff anymore." Which of the following is the priority behavioral intervention for the nurse to implement?

A 65-year-old individual with a documented history of severe alcohol dependence and combat-related post-traumatic stress disorder is receiving treatment for acute pancreatitis. Exactly 48 hours after admission, the individual's behavior drastically changes. They begin pacing the corridor, sweating profusely, and displaying coarse bilateral hand tremors. The individual suddenly shouts, "The food here is laced with poison! I am leaving right now!" and aggressively steps toward the unit's exit doors.

What is the priority nursing intervention to safely manage this situation?

A nurse is caring for a client with post-traumatic stress disorder (PTSD) on an inpatient mental health unit. Following a loud argument between two other clients in the dayroom, the client retreats to a corner, begins hyperventilating, covers their ears, and screams, "Don't touch me! Keep away!" The client is trembling, visually scanning the room, and clenching their fists. Which initial nursing action is the priority?

A nurse is providing care in a memory-care residential facility. During the late afternoon, a client with moderate Alzheimer's disease becomes severely agitated, pushes their dinner tray onto the floor, and begins crying while demanding to 'go home immediately to cook for my little children.' Which of the following behavioral interventions should the nurse implement first?

While attending a morning community meeting, an adult client abruptly pushes their chair back, begins pacing the room, and yells profanities at the facilitator. Which initial actions should the nurse implement to de-escalate the situation and maintain safety? (Select all that apply)

A young adult client is brought to the emergency department via police after being found wandering in traffic. The client is currently in an examination room, highly agitated, hyperventilating, and throwing medical supplies onto the floor. When staff approach, the client screams, 'They are coming to take me away!' Which of the following initial actions by the nurse are appropriate? Select all that apply.

A client on the inpatient psychiatric unit is experiencing severe anxiety. They are pacing rapidly, hyperventilating, and frantically stating, "I feel like I am going to die!" Which of the following is the priority nursing action?

A client in an outpatient clinic waiting area is becoming visibly frustrated due to a prolonged appointment delay. The client begins pacing rapidly, sighing loudly, and complaining to other visitors about the wait. Which action should the nurse take first?

A nurse on a locked behavioral health unit is caring for an adult client. The client approaches the nurses' station with a raised voice, tightly clenched fists, and demands immediate access to a restricted personal item. When the nurse explains the unit safety policy, the client becomes abruptly escalated, begins aggressively striking the reinforced glass, and shouts threats at the staff. Which of the following initial interventions should the nurse implement? Select all that apply.

A client is receiving cardiac monitoring on a telemetry unit three days after an intentional medication overdose. During the first two days of admission, the client was withdrawn, tearful, and refused to eat. On the morning of the third day, the nurse notes the client is fully dressed, appears highly energized, and exhibits a bright affect. The client approaches the nurse, offers a valuable piece of personal jewelry, and states, "Thank you for everything; I finally know exactly how to fix all my problems." Which behavioral intervention should the nurse implement first?

A client with a history of borderline personality disorder is receiving care on an orthopedic unit following surgical repair of a fractured tibia. The client tells the evening nurse, 'You are the only person who actually cares about me; the day nurses are terrible and ignored my pain.' Later, the client begins shouting in the corridor because a requested snack was unavailable. Which behavioral interventions should the evening nurse implement? Select all that apply.

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?

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.

A client with acute delirium and severe agitation in the emergency department is shouting at staff, refusing care, and attempting to climb over the bed rails. Which interventions should the nurse implement as the initial approach to manage this behavioral escalation? Select all that apply.

A nurse is facilitating a group therapy session at a community mental health center. A client diagnosed with antisocial personality disorder repeatedly talks over others, makes insulting remarks about a peer's clothing, and attempts to dominate the discussion. What is the most appropriate initial nursing action?

A client admitted to an oncology unit is found vigorously pacing the main corridor. The client is clenching their jaw, breathing heavily, and loudly accusing a dietary aide of intentionally withholding their breakfast. What is the priority nursing action to manage this behavior safely?

A nurse on an acute psychiatric unit is reviewing the protocol for managing clients who exhibit escalating, aggressive behavior. According to the principle of least restrictive intervention, arrange the following nursing actions in the correct sequence from least restrictive to most restrictive.