A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?
Explanation & Rationale
A. Administer a sedative medication. While medication may be necessary to help calm the client, it should not be the first intervention. De-escalation techniques, such as verbal support and acknowledging emotions, should be attempted before resorting to pharmacological intervention. B. Perform a debriefing with the staff. A staff debriefing is important after the crisis has been resolved to review the incident and improve future responses. However, the priority is to de-escalate the client’s agitation and ensure immediate safety. C. Acknowledge the client's emotions. The first action in a crisis is verbal de-escalation. Recognizing and acknowledging the client's feelings helps establish rapport, reduce agitation, and potentially prevent escalation to physical intervention. Using a calm, non-threatening approach can sometimes defuse the situation without needing restraints or medication. D. Place the client in restraints. Restraints should be used only as a last resort when the client poses an imminent threat to themselves or others and other de-escalation techniques have failed. Verbal intervention should always be attempted first.