The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
A . Approach the client on a continuum of least restrictive care.
B . Challenge client’s behavior immediately with steps to prevent injury to self or others.
C . Leave the aggressive client to himself or herself, and take other clients away.
D . To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.
Answer: A
Explanation:
(A) Approaching a client’s aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary).
(B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client’s internal control.
(C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others.
(D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
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