Psychiatric Emergencies — NCLEX Nursing Lesson Mental Health Nursing · RN Track · Psychiatric–Mental Health · Conditions · Psychiatric Emergencies Condition Lesson · NCLEX-PN / NCLEX-RN

When a mental health situation becomes an immediate danger—crisis, suicide risk, and aggression. De-escalation, suicide prevention, the strict rules of restraint and seclusion, emergency medications, and the safety-first reasoning behind all of it.

Builds on prior lessons Assumes the psychiatric foundations, assessment, and disorders lessons. A psychiatric emergency can arise from any of those conditions (depression, psychosis, mania, substance use, personality disorders). Here the focus is the emergency response itself: keeping the patient, staff, and others safe while preserving dignity and rights. A note on this topic This lesson discusses suicide and violence in a clinical, educational context to prepare nurses to intervene safely. If you or someone you know is in crisis, the 988 Suicide & Crisis Lifeline (call or text 988 in the U.S. and Canada) provides free, confidential support. In this lesson

Lesson Objectives
Why This Matters
Overview
"Pathophysiology" of Crisis & Aggression
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Emergency Medications
Nursing Interventions
Restraints & Seclusion
Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield Review
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Apply crisis intervention principles and recognize the phases of crisis.
Perform a suicide risk assessment and implement evidence-based suicide precautions (means restriction, observation, safety planning).
Recognize the aggression/assault cycle and use de-escalation before physical intervention.
Explain the legal and clinical rules for restraints and seclusion (least restrictive, orders, monitoring, documentation) and when they apply.
Describe emergency ("chemical restraint") medications and their safe use.

Why This Matters

Prevalence: psychiatric emergencies are common across EDs, psychiatric units, and med-surg floors. Suicide is a leading cause of death; workplace violence toward nurses is a significant occupational hazard.

Patient safety: these events threaten the life of the patient (suicide, self-harm) and the safety of others (aggression). Interventions like restraint carry their own serious risks (injury, asphyxiation, death) and legal implications—so they must be used correctly and as a last resort.

NCLEX importance: very heavy testing on suicide precautions, de-escalation (verbal first), the restraint/seclusion rules (least restrictive, provider order requirements, monitoring intervals, documentation), emergency medications, delegation, and prioritization.

Why nurses encounter this: the nurse is often first on the scene and legally responsible for patient safety. Knowing the correct, protective response is essential clinical and ethical practice.

Overview

A psychiatric emergency is any situation in which a person's thoughts, feelings, or behaviors create an immediate risk of harm to self or others, or a severe inability to function/care for oneself. The three most tested scenarios:

Emergency	Core threat	First priority
Crisis	Overwhelmed coping; acute distress/disorganization	Ensure safety; restore coping (crisis intervention)
Suicidal patient	Risk of self-harm/death	Safety: assess risk, restrict means, observe closely
Aggressive/violent patient	Risk to self, staff, and others	De-escalate; ensure safety of everyone; least restrictive measures

Crisis (per Aguilera's model) occurs when a stressful event overwhelms a person's usual coping and balancing factors (perception of the event, support systems, coping skills). It is self-limiting (usually resolves in ~4–6 weeks) and can end in growth or dysfunction—early intervention shapes the outcome.

"Pathophysiology" of Crisis & Aggression

The aggression/assault cycle & the least-restrictive ladder Assault cycle — intervene EARLY 1. Triggering: restlessness, pacing, clenched fists 2. Escalation: louder, threats — DE-ESCALATE NOW 3. Crisis: loss of control / violence → ensure safety 4. Recovery: calming, lowered tension 5. Post-crisis: exhaustion, remorse → debrief The earlier you intervene, the less restrictive the measure needed Least-restrictive ladder (try top first) 1. Verbal de-escalation & active listening 2. Reduce stimulation / offer space & choices 3. Offer PRN oral medication voluntarily 4. Emergency IM medication (chemical restraint) 5. Seclusion / physical restraint (LAST resort) Restraint/seclusion only when less restrictive measures fail Golden rule: safety of everyone + LEAST restrictive intervention that works Verbal de-escalation is always tried first when it is safe to do so.

Aggression escalates through a predictable cycle—the earlier you intervene, the less restrictive the measure needed. Always climb the least-restrictive ladder from verbal de-escalation upward; restraint/seclusion is the last resort.

Normal: a person under stress uses coping skills, support, and realistic appraisal to maintain equilibrium. ↓ What goes wrong: an overwhelming stressor + inadequate coping/support → crisis (disequilibrium). High arousal, fear, or psychosis can drive suicidal or aggressive behavior. ↓ How it manifests: anxiety, disorganization, hopelessness (suicide risk), or escalating agitation (assault cycle). The nervous system is in fight-or-flight; reasoning narrows. ↓ Progression: without intervention → self-harm/suicide or violence. With early, skilled intervention → de-escalation, safety, and restored coping.

Risk Factors

Category	Examples
Non-modifiable	Prior suicide attempt (strongest predictor), history of violence (strongest predictor of future violence), psychiatric diagnosis (psychosis, mania, depression, substance use, personality disorders), male sex & older age (completed suicide), trauma history
Modifiable	Access to lethal means, active substance use/intoxication, untreated symptoms, pain, agitation, social isolation, medication nonadherence
Preventable/protective	Means restriction, treatment adherence, strong support, safety planning, early de-escalation, environmental safety (ligature-resistant units)
High-risk populations	Recently admitted or discharged psychiatric patients, intoxicated/withdrawing patients, acutely psychotic/manic patients, those with command hallucinations, and patients who suddenly become calm after being suicidal

Signs & Symptoms

Suicide risk

Category	Findings (and WHY)
Early/warning	Hopelessness, withdrawal, talking about death, giving away possessions, "putting affairs in order" — signal intent forming
Higher risk	A specific plan, access to means, and intent; prior attempt; command hallucinations to self-harm — greater lethality
Unexpected/red flag	Sudden calm/improved mood in a previously suicidal patient — may mean a decision to act (now has energy) — increased, not decreased, risk
Emergency	Active suicidal ideation with plan/means, or an attempt in progress — immediate intervention

Escalating aggression

Stage	Findings (and WHY)
Early (triggering)	Restlessness, pacing, clenched fists/jaw, loud/rapid speech, invading space — rising arousal; the best time to de-escalate
Escalation	Threats, refusing redirection, throwing objects — control slipping
Emergency	Physical aggression/violence, self-harm — ensure safety of all; use least restrictive effective measure

Nursing Assessment

Subjective

Ask directly about suicide ("Are you thinking of killing yourself? Do you have a plan? Do you have access to means?") and about thoughts of harming others. Assess the crisis (precipitating event, perception, supports, coping), substance use, and history of attempts/violence. Asking about suicide does not increase risk—it opens the door to help.

Objective

Observe behavior and arousal (pacing, agitation, affect), mental status (thought content: hopelessness, delusions, command hallucinations; judgment/insight), signs of intoxication/withdrawal, and any self-harm injuries. Scan the environment for hazards/means.

Priority findings & red flags — act & notify immediately

Active suicidal or homicidal ideation with plan/means, or a sudden calm after suicidality.
Escalating aggression (threats, loss of control) or command hallucinations to harm.
Access to lethal means or an unsafe environment.
Any patient in restraint/seclusion showing distress, airway/circulation compromise, or injury.

Why "ask directly" and "restrict means" are the core of suicide prevention Directly asking about suicide gives the patient permission to disclose and lets you gauge risk. Means restriction (removing sharps, belts, cords, medications; a safe environment; close/1:1 observation) is one of the most evidence-based ways to prevent suicide—because many attempts are impulsive, and reducing access to lethal means saves lives.

Diagnostic Tests

Test/tool	Purpose / why ordered	Findings & nursing considerations
Columbia Suicide Severity Rating Scale (C-SSRS)	Structured suicide risk assessment	Guides level of observation and safety planning.
SAD PERSONS / risk factors review	Estimate suicide risk factors	Higher scores → higher risk/level of care.
Violence/agitation scales	Gauge agitation and predict aggression	Guide early de-escalation and staffing.
Mental status exam	Identify psychosis, mania, command hallucinations, impaired judgment	Determines contributing diagnosis and safety needs.
Medical screening / imaging	Rule out medical causes of altered behavior	New agitation may be delirium, hypoxia, hypoglycemia, or intoxication—rule out medical causes.

Laboratory Tests

Labs don't diagnose the emergency but rule out reversible medical causes of agitation/altered behavior and guide medication safety.

Lab	Purpose	Significance & nursing implications
Point-of-care glucose	Rule out hypoglycemia	Hypoglycemia can cause agitation/altered behavior—check and treat.
Toxicology / blood alcohol	Identify intoxication/withdrawal	Substances are a common cause of psychiatric emergencies; guides management.
Electrolytes, BUN/creatinine, O₂ sat	Rule out metabolic/hypoxic causes of delirium	Correct reversible causes; new confusion in older adults = think delirium.
CBC, infection workup	Rule out infection-related delirium	Especially in older adults.
Medication levels (e.g., lithium)	Rule out toxicity presenting as altered behavior	Toxicity can mimic a psychiatric emergency.

Emergency Medications ("Chemical Restraint")

Why: when de-escalation fails and a patient is a danger, rapid-acting medications calm severe agitation to protect the patient and others. They are used voluntarily first (oral) when possible; involuntary IM administration follows the same legal safeguards as physical restraint.

Antipsychotics

Haloperidol (often IM) for acute agitation/psychosis. Watch for: EPS/acute dystonia, QT prolongation, and NMS. Second-generation options (olanzapine, ziprasidone) are also used.

Benzodiazepines

Lorazepam calms agitation and is first-line for alcohol/benzo withdrawal-related agitation. Watch for: respiratory depression and over-sedation (especially with alcohol/opioids).

Antihistamine adjunct

Diphenhydramine is sometimes added for sedation and to counteract EPS from haloperidol. The combination haloperidol + lorazepam + diphenhydramine is a common emergency regimen.

Safety with emergency medications After giving a sedating IM combination, monitor airway, breathing, sedation level, and vital signs closely (risk of respiratory depression and over-sedation), watch for acute dystonia (treat with anticholinergic), and continue the required observation. Document the behavior, less-restrictive measures tried, the order, and the response. NCLEX pearl — medication is still a restraint A medication given to control behavior (not to treat a diagnosed condition) is a chemical restraint and carries the same requirements as physical restraint: a provider order, least-restrictive justification, monitoring, and documentation. Always try voluntary/oral and de-escalation first.

Nursing Interventions (Priorities)

Safety of everyone FIRST: ensure the safety of the patient, staff, and other patients. Keep a safe distance and a clear exit, call for help/enough staff, and remove other patients from the area. Why: you can't help anyone if the scene isn't safe. ↓ Verbal de-escalation (least restrictive): stay calm, speak in a low, slow voice, use short simple statements, acknowledge feelings, offer choices, set clear limits, and reduce stimulation. Don't argue, threaten, or crowd. Why: most agitation resolves with skilled verbal intervention—preventing escalation and restraint. ↓ Suicide precautions: assess risk, restrict means, provide close or 1:1 observation, stay with the patient, and create a safety plan. Why: reducing access and increasing supervision prevent impulsive self-harm. ↓ Escalate the least-restrictive ladder only as needed: offer voluntary oral medication; if danger persists, emergency IM medication; and only as a last resort, seclusion/restraint per policy. Why: the least restrictive effective measure protects both safety and rights. ↓ ABCs & physiologic monitoring: after sedation or during restraint, monitor airway, breathing, circulation, and skin/circulation to restrained limbs; rule out medical causes of agitation. Why: sedation and restraint carry real physical risks (respiratory depression, asphyxiation, injury, DVT). ↓ Debrief & interdisciplinary care: after the event, debrief with the patient and team, document thoroughly, and involve psychiatry, security, and social work. Why: learning and continuity improve future safety.

Restraints & Seclusion — The Rules

Restraint/seclusion is a last resort to prevent imminent harm when less restrictive measures have failed. The NCLEX tests these safeguards heavily:

Rule	Why it matters
Least restrictive first	Try de-escalation and voluntary measures before restraint—restraint is only for imminent danger.
Provider order required	Needs a provider's order; in an emergency a nurse may initiate, but must obtain the order promptly (per policy/timeframe). Orders are time-limited and never PRN.
Face-to-face evaluation	A provider must evaluate the patient in person within the required time window (e.g., within 1 hour per CMS for violent/self-destructive behavior).
Time-limited orders	Behavioral restraint orders are limited (e.g., up to 4 hr adults, 2 hr ages 9–17, 1 hr under 9) and must be renewed—reassess to release ASAP.
Continuous/close monitoring	Monitor circulation, airway, breathing, skin integrity, vital signs, hydration, toileting, and comfort at frequent intervals; a patient in restraint is never left unattended in seclusion without monitoring.
Discontinue early	Release as soon as the patient is safe—use the least amount of time necessary.
Documentation	Document behavior, less-restrictive measures tried, order, type, monitoring, care provided, and the patient's response/criteria for release.

Restraint is a safety intervention — and a safety risk Restraints can cause injury, impaired circulation, aspiration, asphyxiation, and death. They are used only to prevent harm, never for staff convenience, punishment, or discipline. Apply per policy, monitor continuously, meet basic needs, and remove as soon as safe.

Potential Complications

Complication	Early signs	Nursing/emergency response
Completed suicide/self-harm	Plan, means, sudden calm, self-injury	1:1 observation, remove means, stay with patient, notify—top priority.
Injury to patient/staff (violence)	Escalating agitation, threats	De-escalate early, ensure safety, adequate staff, least-restrictive measures.
Restraint injury/asphyxiation	Distress, positional compromise, decreased circulation	Continuous monitoring, correct positioning, release ASAP—emergency if compromised.
Over-sedation/respiratory depression (meds)	Decreased LOC, slow/shallow breathing, low SpO₂	Support airway/breathing, monitor, reverse if needed—emergency.
Acute dystonia/NMS (antipsychotics)	Muscle spasm; fever + rigidity + altered LOC	Anticholinergic for dystonia; stop drug and support for NMS—emergency.
Missed medical cause (delirium)	New agitation, fluctuating consciousness	Rule out hypoxia/hypoglycemia/infection/intoxication.

Patient & Family Education

Crisis & coping: teach that a crisis is time-limited and that coping skills, support, and professional help improve outcomes. Provide a personalized safety plan (warning signs, coping strategies, contacts, means restriction, crisis line).

Suicide prevention at home: remove or secure lethal means (firearms, medications), maintain follow-up and adherence, and use the 988 Suicide & Crisis Lifeline. Teach families warning signs and to seek help immediately for any suicidal statement or attempt.

Medication & follow-up: take psychiatric medications as prescribed; understand that stopping can trigger relapse. Keep follow-up appointments and connect with support resources.

When to seek emergency care: any thoughts or plan of suicide or harming others, an attempt, escalating agitation, command hallucinations, or inability to stay safe—call 988 or emergency services.

Clinical Judgment (NCSBN Model)

On a psychiatric unit, a patient is pacing rapidly, speaking loudly, clenching his fists, and shouting that staff are "against" him. Other patients are nearby. He refuses to sit down.

Recognize cues

Pacing, loud speech, clenched fists, and paranoid statements = early-to-escalating aggression (the triggering/escalation phase).

Analyze cues

He is escalating and could become violent—risk to himself, staff, and nearby patients. This is the window for de-escalation.

Prioritize hypotheses

Priority: safety of everyone using the least restrictive effective intervention.

Generate solutions

Ensure safety (space, exit, help, move other patients), verbal de-escalation (calm voice, acknowledge feelings, offer choices, reduce stimulation), and offer voluntary oral PRN medication; escalate only if needed.

Take action

Approach calmly with adequate staff, keep a safe distance/clear exit, speak slowly and simply, acknowledge his frustration, set clear limits, offer a quiet space and oral medication. If he becomes physically dangerous despite this, follow policy for emergency medication and, as a last resort, seclusion/restraint with a provider order and monitoring.

Evaluate outcomes

Success = de-escalation, no harm, restored calm, and the least restrictive measure used. Debrief with the patient and team afterward.

Clinical Connections — Commonly Confused

	De-escalation (verbal)	Restraint/seclusion
When used	First, early in the cycle	Last resort, imminent danger only
Requirements	Skill, calm, staffing	Provider order, face-to-face eval, time-limited, monitoring, documentation
Risks	Minimal	Injury, asphyxiation, death, trauma
Priority nursing	Acknowledge feelings, offer choices	Continuous monitoring, meet needs, release ASAP

	Crisis	Chronic mental illness
Onset/duration	Acute, time-limited (~4–6 wk)	Ongoing/long-term
Cause	Overwhelming stressor + inadequate coping	Underlying psychiatric disorder
Goal	Restore baseline coping/equilibrium	Long-term management/recovery
Priority nursing	Safety + short-term problem solving	Ongoing treatment, adherence, support

	Voluntary admission	Involuntary commitment
Basis	Patient consents	Danger to self/others or grave disability (legal criteria)
Rights	May request discharge	Retains rights (e.g., to refuse some treatment) except as legally limited; due process required
Priority nursing	Support engagement	Safety + protect patient rights/dignity

NCLEX High-Yield Review

What the NCLEX Wants You to Know

Safety of everyone is the #1 priority in any psychiatric emergency
Ask about suicide directly; restrict means; use close/1:1 observation
Sudden calm in a suicidal patient = INCREASED risk
De-escalate verbally FIRST; restraint/seclusion is the LAST resort
Restraint: provider order, time-limited, NEVER PRN, face-to-face eval, continuous monitoring
Restraint is never for convenience, punishment, or discipline
Chemical restraint = same rules as physical restraint
New agitation? Rule out medical causes (hypoglycemia, hypoxia, delirium, intoxication)

Common distractors: going straight to restraint instead of de-escalation; using PRN restraint orders (not allowed); leaving a restrained/secluded patient unmonitored; believing asking about suicide increases risk; reading sudden calm as recovery; using restraint for staff convenience. Delegation: the RN assesses risk, leads de-escalation, gives meds, and evaluates; UAP can provide 1:1 observation as directed, stay with a patient, and obtain vitals—not assess risk, de-escalate independently, or apply restraints without RN oversight per policy. Frequently tested meds: haloperidol, lorazepam, diphenhydramine (monitor sedation/EPS/respiratory status). Most common mistakes: skipping least-restrictive steps, inadequate monitoring, and poor documentation.

Memory Aids

Least restrictive ladder: Talk → Reduce stimulation/choices → Offer oral med → Emergency IM med → Seclusion/restraint (last).
De-escalation "CALM": Calm low voice, Acknowledge feelings, Limit-set clearly, Move to a safe/low-stimulation space (with an exit).
Restraint rules "OTTO": Order required, Time-limited, Try least restrictive first, Observe/monitor continuously (never PRN, never for convenience).
Suicide screen "SAD PERSONS": Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.
Sudden calm = red flag: a suddenly peaceful suicidal patient may have decided to act.
Assault cycle: Trigger → Escalation → Crisis → Recovery → Post-crisis—intervene early.
Chemical restraint reminder: "A calming shot to control behavior is still a restraint"—same rules apply.

Case Study

A patient is admitted to the ED after a suicide attempt (overdose). Medically stabilized, she is now tearful, hopeless, and says, "I should have finished the job." She has a history of a prior attempt. Later in the shift she suddenly appears calm and pleasant and asks to be left alone to rest.

Recognize & analyze cues

Recent attempt, hopelessness, statements of continued intent, and a prior attempt = high suicide risk. The sudden calm is a red flag—possibly a decision to act, not improvement.

Prioritize & plan

Priority: safety. Maintain 1:1 continuous observation, restrict means (safe room, remove sharps/cords/medications), and do not leave her alone despite her request.

Take action

Provide 1:1 observation, ensure a ligature-safe environment, assess ongoing ideation/plan, use therapeutic communication, notify the provider, and begin safety planning; anticipate psychiatric evaluation and possible involuntary hold if she meets criteria.

Evaluate & discharge

Success = the patient remains safe, risk is reassessed, and a safety plan is in place. Before discharge/transfer: means restriction at home, follow-up, support resources, and the 988 line. Continue monitoring—risk persists even as mood appears to improve.

NCLEX Practice Questions

Answer choices are numbered; the correct answer is given as a number.

1. A patient on a psychiatric unit is becoming increasingly agitated—pacing, raising his voice, and clenching his fists. What is the nurse's best initial action?

Place the patient in seclusion immediately
Use a calm voice, acknowledge his feelings, and attempt verbal de-escalation
Apply physical restraints to prevent escalation
Administer an IM medication without speaking to him

Rationale

Answer: 2. Verbal de-escalation is the least restrictive first-line intervention. Seclusion (1), restraints (3), and involuntary IM medication (4) are more restrictive and used only after less restrictive measures fail.

2. A patient hospitalized after a suicide attempt suddenly becomes calm and cheerful and asks the nurse to leave so she can rest alone. The nurse should:

Reduce the level of observation since she is improving
Document improvement and prepare for discharge
Maintain close/continuous observation and reassess suicide risk
Honor her request for privacy

Rationale

Answer: 3. A sudden calm in a suicidal patient can signal a decision to act—increase vigilance and reassess risk, don't reduce observation (1), discharge (2), or leave her alone (4).

3. Which statement about the use of restraints is correct?

Restraints require a provider order, are time-limited, and can never be ordered PRN
Restraints may be used for staff convenience when the unit is short-staffed
A restrained patient can be checked once per shift
Restraints do not require documentation if brief

Rationale

Answer: 1. Restraints require a provider order, are time-limited, and are never PRN. They are never for convenience (2), require continuous/frequent monitoring (not once a shift, 3), and must be thoroughly documented (4).

4. A newly admitted patient becomes acutely confused and agitated. Before assuming a psychiatric cause, the nurse should first:

Place the patient in seclusion
Administer a scheduled antipsychotic
Restrain the patient for safety
Assess for reversible medical causes such as hypoglycemia or hypoxia

Rationale

Answer: 4. New agitation/confusion can be delirium from a medical cause (hypoglycemia, hypoxia, infection, intoxication)—rule these out first. Seclusion (1), medication (2), and restraint (3) are not the first step.

5. A patient in emotional crisis states, "I don't know how I'll get through this." Which nursing approach best reflects crisis intervention?

Explore childhood conflicts in depth
Focus on safety and help the patient identify immediate coping strategies and supports
Tell the patient to stop worrying and relax
Delay any action until the crisis resolves on its own

Rationale

Answer: 2. Crisis intervention is present-focused: ensure safety and mobilize immediate coping and supports. Deep insight work (1) isn't the focus in crisis, dismissing feelings (3) is nontherapeutic, and waiting passively (4) is unsafe.

6. SATA. Which are appropriate suicide precautions for a high-risk patient? Select all that apply.

Remove potentially harmful items (sharps, belts, cords)
Provide one-to-one or close continuous observation
Allow the patient to keep the door closed for privacy
Ask directly about suicidal thoughts, plan, and means
Develop a safety plan with the patient

Rationale

Answers: 1, 2, 4, 5. Means restriction, close observation, direct assessment, and safety planning are evidence-based. Allowing a closed door for privacy (3) removes needed observation and is unsafe for a high-risk patient.

7. SATA. Which nursing responsibilities apply when a patient is placed in restraints? Select all that apply.

Obtain a provider order (or obtain one promptly if initiated in an emergency)
Monitor circulation, airway, breathing, skin, and vital signs frequently
Meet needs for hydration, toileting, and comfort
Leave the patient alone until calm to avoid overstimulation
Discontinue restraints as soon as the patient is safe

Rationale

Answers: 1, 2, 3, 5. Orders, continuous monitoring, meeting basic needs, and early release are required. Leaving the patient unmonitored (4) is unsafe—restrained patients require continuous observation.

8. Priority. The nurse is caring for four patients. Which requires attention first?

A patient requesting a PRN sleep medication
A patient in crisis asking to speak with the nurse
A patient who has a suicide plan and was just found with a hoarded supply of pills
A patient asking about visiting hours

Rationale

Answer: 3. A patient with a plan and access to means (hoarded pills) is at imminent risk—intervene first (remove means, 1:1 observation). The others are non-urgent.

9. Delegation. Which task can the RN appropriately delegate to unlicensed assistive personnel (UAP)?

Providing continuous one-to-one observation of a suicidal patient as directed
Performing the suicide risk assessment
Leading verbal de-escalation of an aggressive patient
Determining whether restraints are needed

Rationale

Answer: 1. UAP can provide 1:1 observation under RN direction. Risk assessment (2), de-escalation (3), and restraint decisions (4) require the RN.

10. NGN Case Study. An agitated patient in the ED is shouting, threatening staff, and pacing. De-escalation has been attempted but he lunges toward a staff member. A provider orders emergency IM medication and, if needed, restraints.

10a. Which actions are appropriate at this point? Select all that apply.

Ensure adequate staff and everyone's safety before approaching
Administer the ordered IM medication
Continue only verbal de-escalation despite the physical aggression
Apply restraints as a last resort per policy if danger continues
Move other patients away from the area

Rationale

Answers: 1, 2, 4, 5. With active physical aggression after failed de-escalation, ensure safety/staffing, give the ordered medication, use restraints as a last resort, and protect others. Continuing only verbal de-escalation (3) is unsafe once he is physically attacking.

10b. After restraints are applied, which nursing actions are required? Select all that apply.

Monitor circulation, airway, breathing, and skin frequently
Ensure a provider order and face-to-face evaluation per policy
Leave the patient alone in restraints until the next shift
Provide hydration, toileting, and comfort; document care
Reassess and discontinue restraints as soon as the patient is safe

Rationale

Answers: 1, 2, 4, 5. Continuous monitoring, order/face-to-face evaluation, meeting basic needs/documentation, and early release are required. Leaving the patient alone until next shift (3) violates monitoring standards and is dangerous.

Key Takeaways

Safety of everyone is the first priority in any psychiatric emergency—patient, staff, and others.
Suicide prevention: ask directly, restrict means, use close/1:1 observation, and make a safety plan. A sudden calm in a suicidal patient signals increased risk.
De-escalate verbally FIRST; climb the least-restrictive ladder only as needed. Restraint/seclusion is the last resort.
Restraint rules: provider order, time-limited, never PRN, face-to-face evaluation, continuous monitoring, meet basic needs, document, and release ASAP. Never for convenience, punishment, or discipline.
Chemical restraint (medication to control behavior) follows the same rules as physical restraint; try voluntary/oral first. Monitor for over-sedation, respiratory depression, EPS, and NMS.
Rule out medical causes of new agitation (hypoglycemia, hypoxia, delirium, intoxication) before assuming a psychiatric cause.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). APA.
Halter, M. J. (2022). Varcarolis' foundations of psychiatric-mental health nursing: A clinical approach (9th ed.). Elsevier.
Townsend, M. C., & Morgan, K. I. (2020). Psychiatric mental health nursing: Concepts of care in evidence-based practice (10th ed.). F. A. Davis.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN mental health nursing review module (11th ed.). ATI Nursing Education.
Centers for Medicare & Medicaid Services. (2023). Conditions of participation: Patients' rights — restraint and seclusion (42 CFR §482.13). U.S. Department of Health and Human Services. https://www.cms.gov
The Joint Commission. (2024). National patient safety goals and standards on restraint, seclusion, and suicide prevention. https://www.jointcommission.org
Substance Abuse and Mental Health Services Administration. (2024). Crisis services and the 988 Suicide & Crisis Lifeline. SAMHSA. https://www.samhsa.gov

Psychiatric Emergencies

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