A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client’s voice.
Which of the following interventions should the nurse implement first?.
A.
Obtain a prescription for haloperidol.
B.
Take the client to the seclusion room.
C.
Verbally de-escalate the client.
D.
Place the client in restraints.
The Correct Answer and Explanation is:
Correct Answer: C. Verbally de-escalate the client.
Explanation:
When a client is becoming increasingly agitated, anxious, and tense, with signs such as a clenched jaw and a change in voice pitch, the primary goal of the nurse should be to prevent the escalation of agitation and ensure the safety of both the client and others. The correct first intervention in this situation is C. Verbally de-escalate the client. Verbal de-escalation is a therapeutic communication technique aimed at calming the client and reducing their agitation through empathy, active listening, and clear, non-confrontational communication.
Why Verbal De-escalation First?
- Safety and Client-Centered Care: Verbal de-escalation is a non-invasive, non-restrictive approach that respects the client’s autonomy and dignity. It is in line with the least restrictive intervention principle, which is a key tenet of psychiatric and mental health care. This approach can help the client regain control over their emotions without the need for physical or chemical restraints.
- Prevention of Escalation: Early intervention through verbal de-escalation can prevent the situation from worsening. The goal is to address the client’s anxiety and tension before it leads to aggressive or violent behavior. Effective de-escalation techniques include speaking in a calm and reassuring tone, acknowledging the client’s feelings, and offering choices to help the client feel more in control.
- Therapeutic Rapport: Engaging the client verbally allows the nurse to maintain and strengthen the therapeutic relationship. This rapport is essential for trust and can facilitate better outcomes in managing the client’s emotional state.
Why Not Other Options?
- A. Obtain a prescription for haloperidol: While haloperidol, an antipsychotic medication, may be used to manage severe agitation or psychosis, it is not the first-line intervention. Administering medication without attempting verbal de-escalation first does not align with the principle of using the least restrictive measures. Additionally, medications can have side effects, and their use should be carefully considered.
- B. Take the client to the seclusion room: Seclusion is a more restrictive intervention and should only be used if the client poses an immediate risk to themselves or others and if less restrictive measures, such as verbal de-escalation, have failed. Moving the client to a seclusion room may escalate their agitation if not handled properly.
- D. Place the client in restraints: Physical restraints are highly restrictive and are associated with numerous risks, including physical injury and psychological trauma. Restraints should only be used as a last resort when all other interventions have failed, and the client poses an imminent threat to safety.
In summary, the nurse should first attempt to verbally de-escalate the client, as it is the safest, least restrictive, and most client-centered approach in managing agitation and preventing further escalation.