hard · NCLEX-RN psychosocial
Age: 29 | Location: Inpatient Behavioral Health Unit | Diagnosis: Acute Mania with Paranoid Ideation | Assessment: Client is pacing rapidly, shouting at unseen entities, and clenching their fists. They are invading the personal space of other clients and refusing to follow verbal directions.
The nurse is initiating crisis de-escalation protocols. Sequence the immediate non-pharmacological and safety steps from first to last.
- Maintain a safe physical distance of at least two arm-lengths and ensure clear exit paths for both nurse and client.
- Stand at a 45-angle (supportive stance) with hands open, relaxed, and fully visible to the client.
- Use a calm, low-pitched, and steady voice to acknowledge the client's distress using brief concrete statements.
- Offer clear, simple behavioral choices and set firm, respectful boundaries for acceptable behavior on the unit.
- Administer ordered emergency PRN intramuscular haloperidol and lorazepam if the client remains highly agitated and dangerous.
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