The nurse is performing an initial assessment on a mental health patient in the emergency department. The patient is uncooperative, and the nurse recognizes the patient's behavior is escalating. The most appropriate response by the nurse is to

Question

Quizplus · Accepted Answer

Deescalation tips for mental health emergencies:
F1F1F1S1F1F1F10 Use a nonthreatening stance-open, but not vulnerable. Have them "take a seat"
F1F1F1S1F1F1F10 Eye contact-not constant, brief to show concern
F1F1F1S1F1F1F10 Commands-brief, slow, with simple vocabulary, only as loud as needed, repeat as needed
F1F1F1S1F1F1F10 Movement-not sudden, announce actions when possible, keep hands where they can be seen
F1F1F1S1F1F1F10 Attitude-calm, interested, firm, patient, reassuring, respectful, truthful
F1F1F1S1F1F1F10 Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the patient ("I understand you are seeing or feeling this, but I am not")
F1F1F1S1F1F1F10 Remove distractions, upsetting influences
F1F1F1S1F1F1F10 Keep the patient talking/focused on the here and now
F1F1F1S1F1F1F10 Ignore, rather than argue with, provocative statements
F1F1F1S1F1F1F10 Allow verbal venting, within reason
F1F1F1S1F1F1F10 Be sensitive to personal space/comfort zone
F1F1F1S1F1F1F10 Remove patient to a quiet space; remove others from immediate area (avoid the "group spectators")
F1F1F1S1F1F1F10 Give some choices or options, if possible
F1F1F1S1F1F1F10 Set limits, if necessary
F1F1F1S1F1F1F10 Limit interaction to just one professional and let that person do the talking
F1F1F1S1F1F1F10 Avoid rushing-slow things down
F1F1F1S1F1F1F10 Give yourself an out; don't put the patient between yourself and the door

The Nurse Is Performing an Initial Assessment on a Mental