A manic client is pacing the halls of the inpatient unit and making disruptive comments to the other clients
The nurse overhears the client say, "I know people, so you better treat me with respect!" Which of the following therapeutic nursing interventions would the nurse implement first? 1. Notify security that this client is escalating out of control and the client needs to be escorted to the client's room.
2. Tell the client that the nurse would like to give a PRN injection because the behavior is disrupting others.
3. Approach the client and say in firm voice, "That was inappropriate. Go to your room immediately."
4. Address the client and say in a calm voice, "The staff will work hard to make sure you receive proper respect here. Let's go over here and talk."
4
Rationale: Reassuring the client that the client will be respected validates the client's need for respect and provides an opportunity to further assess the client's ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the client's needs, not others.
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