The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse?
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse?
A. Restrain the client
[2%]
B. Escort the other clients from the room
[29%]
C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption
[3%]
D. Approach the client causing a disruption calmly while accompanied by two additional staff members
[66%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Crisis Intervention
Item Type
Item Type
Analysis
Explanation
Choice D is correct. The initial intervention is to approach the client calmly, attempt to de-escalate the situation, and remove this client from the room (preferably on the client's own accord). For the safety of staff and all other individuals in the room, staff members should never make face-to-face contact with an agitated psychiatric client without being accompanied by other trained healthcare personnel.
Choice A is incorrect. The use of physical restraints for this client (or any client) is typically reserved as a final approach. The first nursing intervention should be an attempt by the nurse to verbally de-escalate the situation with the goal of ultimately removing the client from the room peacefully.
Choice B is incorrect. Unless the situation escalates to the point where the other clients are placed in physical danger, the nurse should try to avoid removing the other clients from the room, as these clients are not the individuals causing the issue at hand. The primary goal for the nurse in this situation should be to remove the disruptive client from the room.
Choice C is incorrect. Although an intramuscular (IM) injection of haloperidol may be indicated at some point, this is not the most appropriate action for the nurse at this time. First, even if the client has an existing PRN order for this medication, accessing and preparing the medication will take time. Second, the client is currently agitated. Attempting to physically restrain the client to provide the client with an IM haloperidol injection will not only increase the client's agitation but significantly jeopardize the nurse and other staff members' safety. Third, an IM injection of haloperidol does not work instantaneously, as the medication's onset of action is approximately 15 minutes. Therefore, before resorting to an IM injection of haloperidol, the nurse should exhaust all other less invasive options.
Learning Objective
When caring for a client with paranoid schizophrenia who is yelling and blocking the television in a room full of other psychiatric clients, identify that the most appropriate nursing action is to approach the disruptive client calmly while accompanied by two additional staff members.
Related Videos
2 Key Topics
Schizophrenia
32.3 Major Psychiatric Disorders
Additional Info
✓ Aggressive and disruptive behavior in a facility poses a serious challenge for nurses, clinical staff, and fellow clients.
✓ Studies have found that clients with major depressive disorder exhibit significantly higher externally directed aggression, reactive aggression, and irritability than controls.
✓ Studies have also shown clients with schizophrenia tend to display higher irritability with distinctly higher self-aggressiveness than healthy persons.
