Psychosocial Integrity Q 2
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
A. Call security for assistance and prepare to sedate the client.
B. Tell the client to calm down and ask him if he would like to play cards.
C. Tell the client that if he continues his behavior he will be punished.
D. Leave the client alone until he calms down.
Correct Answer: A. Call security for assistance and prepare to sedate the client.
If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer medication such as Haldol to sedate him. Alert staff if a potential for seclusion appears imminent. Usual priority of interventions would be: firmly setting limits; chemical restraints (tranquilizers); and seclusion. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted.
Option B: Telling the client to calm down will not work. Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions.
Option C: Telling the client that if he continues he will be punished is a threat and may further anger him. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania. Use a calm and firm approach; provide structure and control for a client who is out of control.
Option D: If the client is left alone he might harm himself. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room); helps decrease the escalation of anxiety and manic symptoms.