# A psychiatric inpatient is pacing, shouting, and clenching the fists, and the nurse identifies an escalating risk of violence. Which actions are appropriate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A psychiatric inpatient is pacing, shouting, and clenching the fists, and the nurse identifies an escalating risk of violence. Which actions are appropriate? Select all that apply.

1

Reduce environmental stimulation and remove objects that could be used as weapons while assessing for medical, substance-related, or situational triggers

2

Stand close and directly in front of the client, maintain prolonged eye contact, order the client to calm down, and threaten restraint if the behavior continues

3

Offer prescribed oral PRN medication early when the client can collaborate, while continuing verbal de-escalation and monitoring the response

4

Use restraint or seclusion for immediate safety only after less restrictive measures fail, follow time-limited order and monitoring requirements, and complete the required face-to-face evaluation within 1 hour

5

Maintain a safe exit route, avoid cornering or blocking the client, summon trained assistance, and ensure adequate staff before a physical intervention

6

Approach at a safe distance with an open, nonthreatening posture and calm tone, acknowledge distress, and offer simple choices that preserve control

## Explanation

Use the least restrictive approach that protects the client, staff, and others. Reduce stimulation, remove hazards, and assess contributors to agitation (Choice 1). Calm verbal engagement, adequate personal space, acknowledgment of distress, and simple choices support de-escalation (Choice 6). Offer voluntary oral medication early when appropriate rather than waiting for escalation (Choice 3). Maintain staff safety, avoid trapping the client, and obtain trained assistance (Choice 5). Restraint or seclusion is a last-resort safety intervention; follow the applicable CMS order limits and hospital monitoring policy, and complete the required in-person face-to-face evaluation within 1 hour for violent or self-destructive behavior (Choice 4). Close confrontation, commands, prolonged eye contact, and threats can intensify agitation (Choice 2).

## In-depth explanation

Psychiatric Agitation — Stages
1. Anxiety: pacing, restlessness, fidgeting
2. Defensive: raised voice, swearing, clenched fists
3. Acting out: imminent risk of violence
4. Tension reduction: post-event recovery, debrief

Verbal De-escalation Principles
1. Respect personal space: more than arm's length (2 arm-lengths preferred)
2. Body: open hands, slight angle (not directly facing), at or below the client's eye level
3. Voice: low, even, slow; no shouting
4. Listen; reflect feelings
5. Offer choices: gives sense of control
6. Set limits calmly: clear, simple, respectful
7. Identify and address triggers

Environment
- Remove potential weapons
- Reduce noise/lights/heat
- Maintain clear path to the door for both client and staff
- Adequate staff backup before any physical intervention

Early PRN Medication
Offered during defensive stage BEFORE acting out, with verbal de-escalation continuing. Common: oral lorazepam (BZD), olanzapine (atypical antipsychotic), or combinations per protocol; IM if oral declined and risk imminent.

Restraint — LAST RESORT (CMS)
- After de-escalation + less-restrictive measures fail
- Provider order; time-limited (max 4 hr adult, 2 hr ages 9-17, 1 hr <9)
- q15-min monitoring: respiratory, circulation, behavior, hygiene, comfort, readiness for release
- Face-to-face evaluation by provider within 1 hour
- Document alternatives tried
- Release as soon as criteria met; debrief client + staff

Memory Tip
"Calm-Distance-Choices-Triggers-Early Med-Egress-Restraint LAST"

## Clinical scenario

Scenario
Adult on psychiatric inpatient unit, rising agitation: pacing, raised voice, clenched fists. Imminent violence risk.

Action Map
1. Calm non-threatening approach: open hands, angled body, >arm's length, low voice, choices
2. Triggers + environment: remove noise/light/weapons
3. Early PRN per orders before peak
4. Egress path clear; signal team; adequate staff
5. Restraint LAST: order, CMS time limits, q15-min monitoring, face-to-face within 1 hr, document alternatives

Avoid
- Standing directly in front, very close
- Authoritarian threats
- Blocking the client's exit
- Restraints before de-escalation attempts

## Key concepts

- **Verbal De-escalation Techniques** — Evidence-based skills for managing escalating agitation: respect personal space (more than arm's length, two arm-lengths preferred), use open non-threatening body language and a low even voice, listen actively and reflect feelings, offer choices to preserve a sense of control, set clear limits calmly, and identify and address triggers. Studies show that early consistent de-escalation reduces the need for involuntary medication and physical restraint, with better outcomes for clients and staff.
- **Restraint Use Standards (CMS, The Joint Commission)** — Restraints are LAST resort after de-escalation and less-restrictive measures fail. Required: provider order (PRN restraint orders are PROHIBITED), time-limited (max 4 hr adult, 2 hr ages 9-17, 1 hr <9 yr), q15-min monitoring of respiratory status, circulation, behavior, hygiene, comfort and readiness for release, face-to-face evaluation by a licensed provider within 1 hour of restraint application, documentation of less-restrictive alternatives tried, and release as soon as criteria are met. Post-event debrief with the client and staff is required.
- **Risk Assessment for Imminent Violence** — Cues that suggest imminent violence: pacing, increasing motor restlessness, raised or threatening voice, clenched fists or jaw, intense or fixed staring, swearing or threats, hyperventilation, refusal to engage, history of recent violence, command auditory hallucinations to harm, intoxication or withdrawal. The nurse who recognizes the rising agitation phase early can intervene with verbal de-escalation, environmental change, and early PRN medication to prevent violence and the need for restraint.

## Related questions

- [A nurse is admitting a 32-year-old client to an inpatient mental health unit with a diagno…](https://mymerci.kr/pages/nclex_q.php?qn_id=360525&lang=en)
- [A 28-year-old client with schizophrenia is admitted to the inpatient psychiatric unit. The…](https://mymerci.kr/pages/nclex_q.php?qn_id=363668&lang=en)
- [A nurse is admitting an adult client to an inpatient behavioral health unit for active sui…](https://mymerci.kr/pages/nclex_q.php?qn_id=363995&lang=en)
- [A nurse is admitting a 22-year-old client to the inpatient psychiatric unit after a suicid…](https://mymerci.kr/pages/nclex_q.php?qn_id=364123&lang=en)
- [A nurse is caring for an adult client newly admitted to the inpatient psychiatric unit who…](https://mymerci.kr/pages/nclex_q.php?qn_id=366332&lang=en)
- [A 60-year-old client with chronic alcohol use disorder is admitted to the emergency depart…](https://mymerci.kr/pages/nclex_q.php?qn_id=368099&lang=en)
- [A 38-year-old client comes to the emergency department voluntarily reporting intrusive vio…](https://mymerci.kr/pages/nclex_q.php?qn_id=368141&lang=en)
- [A client with major depressive disorder quietly states, "I don't see the point in going on…](https://mymerci.kr/pages/nclex_q.php?qn_id=368299&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=368323&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._