A patient has entered the escalation phase of the assault cycle. Select the most appropriate nursing intervention
a. Direct the patient to the quiet room.
b. Process the incident with the patient.
c. Encourage ventilation of feelings.
d. Place the patient in seclusion.
A
During the escalation phase the patient is still capable of cooperation when the nurse takes charge and gives calm, firm directions. This intervention observes the principle of using the least restrictive alternative. Oral PRN medication might be used if the least restrictive alternative is not effective. Ventilation of feelings would have been used in the triggering phase. Processing the incident occurs in the recovery and depression phases. Seclusion is necessary in the crisis phase.
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