Deescalation
A client becomes verbally aggressive and paces the room, clenching fists. What is the nurse’s priority action?
give the client physical space
what is contraband?
items that could be used for self-harm or harm to others.
Which criteria justify placing a client on a 5150 hold?
Danger to self
Danger to others
Gravely disabled
A client with severe depression is admitted to the psychiatric unit. What is the priority nursing action?
Assess for suicidal ideation
Psychoanalytic Theory (Freud)
What is his focus?
Key Concepts: Id, ego, superego, defense mechanisms
A client refuses medication and becomes increasingly agitated. Which response by the nurse is most appropriate?
“Let’s talk about what’s making you agitated.”
A client is admitted involuntarily to the psychiatric unit. When should the nurse conduct a contraband search?
Immediately upon admission
A client on a 5150 asks, “Why can’t I leave?” What is the best nurse response?
“You’re being held for evaluation to help keep you safe.”
Which nursing action demonstrates least restrictive care?
Using verbal de-escalation
Interpersonal Theory (Hildegard Peplau)
what is his focus?
Therapeutic nurse–client relationship
Which intervention should the nurse use last if de-escalation techniques fail?
Physical restraints
Which items should the nurse remove during a contraband search?
List as many as you can
Which client situation most clearly meets 5150 criteria?
imminent threat to self meets criteria for danger to self.
A client on suicide precautions asks why their belongings were removed. What is the best nurse response?
safety-based explanations
Behavioral Theory (Skinner, Pavlov)
what are their focus?
Conditioning, reinforcement
Which intervention demonstrates least restrictive care?
coping strategies
Which client is at highest risk for possessing contraband?
Suicidal patients
Which right does a client on a 5150 retain?
Clients retain basic civil rights, including dignity, food, shelter, and safe care.
Which nursing action is appropriate when a client is placed in restraints?
q15 minute safety checks
What does Milieu Therapy mean?
Therapeutic environment
A client says, “I’m so angry I could explode.” What is the best nurse response?
“I can see you’re upset. Let’s find a way to help you feel safe.”
The nurse discovers contraband in a client’s room. What is the priority action?
Remove the item safely
Which situation would require escalation beyond a 5150?
further legal action (e.g., 5250) may be required.
Which behaviors are warning signs of suicide?
Giving away belongings
Writing goodbye letters
Increased risk-taking
Irregular sleep patterns
What did Maslow focus on in regard to BH?
Personal growth and self-actualization