A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? A)Facilitate immediate removal of people from the area B)Inform the client that the client cannot act that way C)Pull the fire alarm to get additional immediate help D)State that the nurse can see the client is upset

Question

Quizplus · Accepted Answer

When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option B) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option C) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option D) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately.

A Client in the Mental Health Unit Picks Up a Fire