During the morning community meeting, a client with psychosis ...

[jeatrice]

During the morning community meeting, a client with psychosis becomes agitated, making loud threats to no one in particular, but the other clients appear increasingly uncomfortable. What action should the nurse facilitator take?
 
  1. Address the client by name and say, It sounds as if you are experiencing something very disturbing. Please go see the nurse who may be able to help you.
  2. Direct the client by saying, You need to sit quietly and listen until it's your turn to talk.
  3. Accompany the client to his or her room so that the client can de-escalate.
  4. Say to the group, You all appear frightened by this behavior. What should we do about it?

Question 2

After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:
 
  1. The nurse lacks rapport with the client.
  2. The nurse lacks adequate de-escalation and limit setting skills.
  3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurse's skill.
  4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.

[djofnc]

Answer to Question 1

1
Rationale: The client's thought process is preventing the client from receiving any benefit from group and could escalate if not properly attended to. In this scenario, it is not appropriate for the client to remain in the group, and the behavior must be addressed prior to asking the group for input. As the group facilitator, it would not be appropriate to leave the group.

Answer to Question 2

3
Rationale: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurse's verbal skills or ability to establish rapport are not necessarily measured by the client's response, as some clients are more out of control than others.

[jeatrice]

TY

[djofnc]

Happy to Help