Question

the nurse is caring for a client who is agitated and confused. the client is persistently trying to get out of bed and attempted to remove the peripheral iv. the nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. the client yells, "i am going to punch you in the face!" what is the nurse's next action?

Answer 1

Answer: You should first call for security. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client's view can lead to further agitation for the client and increase the risk for escalating to violence.