A patient with a history of command hallucinations approaches the ...

[hubes95]

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario?
 
  Select all that apply.
 
  a. State the expectation that the patient will stay in control.
  b. State that the patient cannot be understood when mumbling.
  c. Tell the patient, You are behaving inappropriately.
  d. Offer to provide the patient with medication to help.
  e. Speak in a firm but calm voice.

Question 2

When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions?
 
  a. Staff members should match the patient's affective level and tone of voice.
  b. Ask the patient what intervention would be most helpful.
  c. Immediately use physical containment measures.
  d. Begin with the least restrictive measure possible.

[LP]

Answer to Question 1

ANS: A, D, E
Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

Answer to Question 2

ANS: D
Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the preaggressive phase but is less effective during escalation.