A patient on a psychiatric inpatient unit is becoming increasingly agitated — pacing, raised voice, fists clenched but not currently striking out. Which de-escalation actions should the nurse implement? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
De-escalation: calm low voice, simple language, offer choices, adequate personal space, do not block exit, reduce stimulation, request team backup, offer PRN medication voluntarily. Choice 3 is wrong — physical restraint is the LAST resort, not the first; verbal de-escalation, environmental modification, and voluntary medication should be tried first per Joint Commission and CMS standards.
The "Verbal de-escalation first" principle is one of the most-tested NCLEX psych points. Restraint comes last after verbal/environmental/voluntary interventions fail. The "exit access" rule protects both staff and patient — never block the door, and ensure the patient has space to retreat as anxiety releases.
Adult patient on inpatient psychiatric unit: pacing, voice raised, fists clenched but not currently striking out. Other patients in the milieu. The nurse leads the team in de-escalation following least-restrictive principles.
Verbal de-escalation — First-line response to agitation: calm voice, simple language, choices, validation, personal space.
Restraint as last resort — Used only when verbal and voluntary interventions fail and risk of harm is imminent; with provider order and continuous monitoring.
Exit access principle — Both nurse and patient must have a clear path to exit; nurse never blocks the door.