When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, “What took you so long to get in here!” Which action should the nurse implement?
A.
Request backup from the staff.
B.
Stand in the doorway.
C.
Provide for personal space.
D.
Encourage the client to sit down.
The Correct answer and Explanation is:
The correct answer is C. Provide for personal space.
Explanation
In a situation where a client is exhibiting aggressive behaviors, pacing, and restlessness, it’s crucial to prioritize safety for both the client and the healthcare provider. The client’s aggressive behavior and verbal outbursts suggest a heightened state of agitation, which can pose a risk of escalation. Here’s why providing personal space is the most appropriate initial action:
- De-escalation: When a client is aggressive and restless, their behavior may be driven by anxiety or a sense of loss of control. By providing personal space, the nurse allows the client to feel less threatened and reduces the chance of the situation escalating further. The client needs space to calm down and regain composure without feeling cornered or threatened.
- Safety: Standing in the doorway or approaching the client too closely could potentially be perceived as a threat, which might increase the client’s agitation or lead to a physical altercation. Ensuring personal space helps minimize the risk of any violent outbursts or self-harm.
- Non-verbal Communication: Providing personal space shows that the nurse respects the client’s boundaries and is not trying to exert control, which can help build trust and facilitate a more calm interaction. It demonstrates an understanding of the client’s need for distance while still maintaining a presence that indicates readiness to assist.
- Assessment and Support: Once personal space is established and the client is less agitated, the nurse can then assess the situation more effectively. This might include understanding the triggers for the client’s aggressive behavior and determining the appropriate interventions, such as offering emotional support or involving additional resources if necessary.
In summary, providing personal space is a foundational step in managing aggressive behavior as it prioritizes safety and helps de-escalate the situation, setting the stage for more effective interventions and support.