The nurse is assisting the social worker and therapist in leading a presentation on life skills to the clients on a psychiatric unit. The client, who has been diagnosed with BPD, begins to threaten another client who constantly interrupts the presentation by asking questions. As the client's behavior escalates, which actions should the nurse take first? Select all that apply.

Question

Quizplus · Accepted Answer

1.This is incorrect. Using a threatening tone with an agitated and aggressive client can lead to escalation in the client's behavior. This can endanger everyone's safety on the unit. The nurse should speak to the client in a soft and calm, but firm, voice when trying to deescalate the client.
2.This is correct. The nurse's first priority is always to maintain the safety of the clients and staff. Asking the clients to leave the room helps ensure that they will not be injured should the client become violent. Using a calm voice when speaking with the clients helps them remain calm.
3.This is incorrect. Administering any medication, including an injectable antipsychotic, is only warranted once other less invasive strategies have been tried and have failed. The nurse must first try to deescalate the client verbally before moving on to physical interventions.
4.This is correct. The nurse's priority is always to maintain the safety of the clients and staff. The nurse asks the social worker and therapist to leave the room to protect them. In addition, the nurse requires backup from the other unit nurses in this situation to help calm the client before he becomes violent. The other staff nurses also need to be notified of the situation so they may help keep the other clients on the unit calm.

The Nurse Is Assisting the Social Worker and Therapist in Leading