Mental Health Psychiatric Care

Crisis Management

Mental Health "Psychiatric Care"

4 Phases

1. Trigger event: anxiety in response to threat

2. Escalation: increasing anxiety & agitation

3. CRISIS: outburst, violence, or shouting

4. Post Crisis Disorganization & Depression

Interventions

1st

... ...

ATI Question

... which of the following best describes what should be in the first box? The triggering event

Kaplan Question

The client states, "I feel like I can barely get out of bed in the morning." The nurse recognizes the client is in which stage of crisis? Disorganization & depression

The triggering

event

Escalation

Crisis

Disorganization

2nd

3rd

Communication

1. Explain all activities of care clearly & calmly NCLEX TIP

2. Eliminate the trigger 3. Low-stimulation environment

- NOT near nurses' station

4. Determine the source of anger

5. Acknowledge the client's emotions

HESI Question

The patient becomes agitated and threatens to harm a member of staff. Which nursing intervention is appropriate?

Address the patient with simple directions and a calming voice

Kaplan Question

When intervening with a violent client, the nurse takes which action? Identifies the nurse to the client and

remains calm

I'm Lily and I'm here to help

ATI Question

Q1: A client becomes agitated and threatens to punch the other client. What is the priority action by the nurse? Eliminate the trigger using nursing measures and interventions

Q2: ... yelling and screaming at the staff... which actions should the nurse take? Determine the true source of the client's anger

Q3: angry and throws a chair in the dayroom. Which of the following interventions should the nurse perform first? Acknowledge the client's emotions

I see you are upset

HESI Question

Q1: A client ... bursts out in a verbal tirade in the dayroom. The client has a history of poor impulse control. What is the nurse's priority action? Remove any other clients from the day room

Q2: When approaching an angry patient, which safety considerations should be taken?

Have other staff as backup, and stand far enough away to avoid injury

Pharmacology

Anxiolytics Benzos: "-pam" "-lam" Lorazepam (brand: Ativan)

Antipsychotics: Haloperidol (brand: Haldol) Ziprasidone (brand: Geodon)

Physical Restraints

1. Get an order for restraints (Renewed every 4 hours for adults)

2. Must be assessed by HCP within 1 hour of order

3. Document every 15 minutes 4. Monitor & meet physical needs

HESI Question

A client who is displaying violent behavior. Which of the following medications should the nurse expect the provider to prescribe? Select all that apply.

Lorazepam Haloperidol Ziprasidone

LORAZEPAM

HALOPERIDOL

Ziprasidone hydrochloride

Geodon

HESI Question

Physical restraints are placed on the client, and then the client is put into a seclusion room. Which actions must the nurse take in the next hour?

Meet the physical needs of the client Obtain a prescription for the restraints Objectively document the client's behavior

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