An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?
Call for an emergency response from trained personnel.
Calmly call the client by name and encourage verbal expression of anger.
Approach the client and firmly say. "Stop. put it down."
Assist the client to use problem-solving techniques instead of aggression
The Correct Answer is A
The safety of both the client and others is the top priority in this situation. The client's aggressive behavior poses a significant risk, and immediate action is necessary. Calling for an emergency response from trained personnel, such as security or other staff members experienced in handling aggressive behavior, can help ensure the situation is properly managed and de-escalated in a safe manner.
Option B may not be appropriate in this situation, as trying to engage the client in verbal expression of anger while they are in an agitated and aggressive state can potentially escalate the situation further.
Option C is not recommended, as approaching the client in a confrontational manner may further escalate their anger and aggression.
Option D, while it may be beneficial in a different context and when the client is in a more stable state, is not appropriate when the client is actively engaged in aggressive behavior. The focus at this moment should be on ensuring the immediate safety of everyone involved.
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Correct Answer is C
Explanation
The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.
By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.
Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.
Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.
Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.
Correct Answer is D
Explanation
Explanation: This response demonstrates the use of therapeutic communication, specifically offering the client an opportunity to express their feelings and concerns in a non-confrontational manner. By suggesting a private and quiet area to talk to, the nurse provides a safe and supportive environment for the client to explore and process their emotions. This approach can help the client feel heard, validated, and understood, which may reduce their need to act out or engage in argumentative behaviors to express their feelings.
The other responses are not as effective or therapeutic:
A. Threatening the client with seclusion is an aggressive approach and may escalate the client's behavior or cause them to feel cornered and defensive, leading to further acting out.
B. Telling the client they have to take medication to stop their behavior does not address the underlying issues that may be causing their behavior. It can also come across as dismissive of the client's feelings and concerns.
C. Saying "I don't know what set you off today but you have to get along with others" may be perceived as dismissive and does not offer the client an opportunity to express their emotions or address their concerns.
In summary, offering a private space to talk and explore the client's feelings in a non-judgmental and supportive manner is the most beneficial therapeutic response to help the adolescent client decrease acting out behaviors and promote positive communication and coping skills.
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