Question

A client with paranoid schizophrenia is experiencing visual hallucinations of people jumping out of nowhere. The client keeps striking the wall. Repeated attempts by the nurse to orient the client to reality and reassure the client of safety have failed. What would be the nurse's next de-escalation approach?
1. Offer the client a PRN medication
2. Apply soft limb restraints on client's wrists
3. Have several staff demobilize the client so that forcible injection can be administered
4. Call security to assist in placing the client in seclusion

Answer

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