The nurse is performing an initial assessment on a mental health client in the emergency department. The client is uncooperative, and the nurse recognizes the client's behavior is escalating. The most appropriate response by the nurse is to
a. use a vulnerable stance.
b. maintain constant eye contact.
c. move quickly with hands hidden behind back.
d. ignore provocative statements.
ANS: D
Deescalation tips for mental health emergencies:
¥ Use a nonthreatening stance—open, but not vulnerable. Have them "take a seat"
¥ Eye contact—not constant, brief to show concern
¥ Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed
¥ Movement—not sudden, announce actions when possible, keep hands where they can be seen
¥ Attitude—calm, interested, firm, patient, reassuring, respectful, truthful
¥ Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client ("I understand you are seeing or feeling this, but I am not")
¥ Remove distractions, upsetting influences
¥ Keep the client talking/focused on the here and now
¥ Ignore, rather than argue with, provocative statements
¥ Allow verbal venting, within reason
¥ Be sensitive to personal space/comfort zone
¥ Remove client to a quiet space; remove others from immediate area (avoid the "group spectators")
¥ Give some choices or options, if possible
¥ Set limits, if necessary
¥ Limit interaction to just one professional and let that person do the talking
¥ Avoid rushing—slow things down
¥ Give yourself an out; don't put the client between yourself and the door
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