A client with a history of violence is admitted to a psychiatric unit.

QUESTION

A client with a history of violence is admitted to a psychiatric unit. The nurse observes the client pacing the halls and speaking to other clients in a menacing way.

The nurse is concerned that the client will become physically violent. The nurse should initially

a. encourage the client to stop pacing and sit down.
b. increase environmental stimuli by promoting more sensory input
c. call the client by name using a low, calm tone of voice
d. refrain from medicating the client

ANSWER:

ANS: C
Deescalation tips for mental health emergencies:
¥ Use a nonthreatening stance—open, but not vulnerable. Have them “take a seat”
¥ Eye contact—not constant, brief to show concern
¥ Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed
¥ Movement—not sudden, announce actions when possible, keep hands where they can be seen
¥ Attitude—calm, interested, firm, patient, reassuring, respectful, truthful
¥ Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client (“I understand you are seeing or feeling this, but I am not”)
¥ Remove distractions, upsetting influences
¥ Keep the client talking/focused on the here and now
¥ Ignore, rather than argue with, provocative statements
¥ Allow verbal venting, within reason
¥ Be sensitive to personal space/comfort zone
¥ Remove client to a quiet space; remove others from immediate area (avoid the “group spectators”)
¥ Give some choices or options, if possible
¥ Set limits, if necessary
¥ Limit interaction to just one professional and let that person do the talking
¥ Avoid rushing—slow things down
¥ Give yourself an out; don’t put the client between yourself and the door