A patient standing in the dining room screams, "You are going to kill me!" He is very agitated and seems extremely frightened. He is mumbling to himself, and his eyes are darting as if tracking an unseen person
He then says repeatedly, "No! I can't! No!" Put the nursing interventions in the order they should be undertaken.
A. Send other staff to report the situation and obtain PRN medication.
B. Assure the patient that staff will make sure that everyone stays safe.
C. Clear the dining room of other patients and unnecessary personnel.
D. Explain that the medication will stop the voices, then administer it.
1 . B
2 . C
3 . A
4 . D
This sequence first assures the patient that staff will help make sure everyone is safe, thus reducing the patient's fearfulness and level of anxiety, in turn reducing his need to act aggressively towards others out of fear. It then protects other patients and nonessential staff from potential harm should the patient act aggressively. The third step secures help from another while allowing the nurse to remain with the patient to provide structure, limits, and a continued sense of security, helping to stave off violent behavior. Last, when the PRN medication arrives, the nurse explains how use of medication will help the patient by reducing the experience of hallucinations that seem to be frightening him. Possible misperceptions of the medication are thus avoided, and the patient's motivation to accept the medication is increased.
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