Reference no: EM133251766

Question - The nurse is caring for a 72-year-old male client who was admitted with new onset confusion and hallucinations of unknown origin. A drug screen has been initiated, and the client is awaiting an MRI of the head. The client does not have a history of mental illness and is placed on the medical-surgical neurologic care unit to undergo further testing. The client appears agitated and is found pacing in the client's room. The family indicates this is not typical behavior for the client and expresses concern. Family members describe the client as mild-mannered but now indicate he doesn't seem to know who they are and seems angry. The client begins mumbling and suddenly yells, "You're trying to poison me!" and points to the nurse. The client continues yelling mostly garbled words and flailing his arms in the air.

a. Which client behaviors are concerning related to potential violence?

b. Review the violence risk assessment tools located on the CDC website. Which tool would be appropriate to use in this scenario?

c. Once you have determined the appropriate tool for violence risk assessment, complete the assessment. What are your results?

d. What benefit would initiating de-escalation techniques have for the client, nurse, and family at this time?

e. Should the nurse ask the family to leave the room? Explain.

f. Identify at least three actions the nurse could take to work toward de-escalation in this scenario.

g. The hospital security team arrives and is standing outside the client's room. Describe any changes you might make to your de-escalation plan.