Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply
a. Project confidence and control.
b. Provide a show of force when appropriate.
c. Ask the agitated patient why they are feeling so aggressive.
d. Move to within 5 feet of the patient to help contain their movement.
e. Provide the patient with several options as means of de-escalating the crisis.
ANS: A, B, E
The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking ‘why' is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation.
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