A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, bitch!" and then goes into the day room. The nurse follows the patient into the day room
Which intervention would be best at this time? a. Stay between the patient and the door for easy exit.
b. Stand out of range of possible assault by the patient.
c. Position oneself about 28 inches from the patient.
d. Sit down in a chair near the patient to convey interest.
B
When intervening with an agitated or potentially violent person, it is essential to stay far enough away that you are safe from a punch, kick, or other potential assault. Personal space needs increase when a person feels anxious, angry, or threatened. Standing between the patient and the door could be interpreted as confrontational or could cause the patient to feel trapped, increasing his fear and agitation. Standing within 28 inches places one within the patient's personal space and within range of being struck. Sitting would make it difficult to protect oneself from assault and is inadvisable until further assessment suggests the patient's aggression is abating.
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