A nurse is assessing a client in the ED who is pacing, clenching their fists, and speaking in a loud and pressured tone. What is the nurse's BEST initial action to prevent the situation from escalating to violence?
Speak to the client in a calm, non-threatening tone and encourage them to express their concerns.
Escort the client to a quieter, private area away from others.
Call for other staff members to assist in case the client becomes violent.
Prepare restraints in case the client becomes physically aggressive.
The correct answer involves employing therapeutic communication to de-escalate the situation and ensure safety. Using a calm, non-threatening tone aligns with behavioral management techniques to help reduce agitation and prevent escalation. Calling for additional staff or preparing for physical intervention can be appropriate in severe escalation but are not the initial steps. Escorting the client to a private room might seem helpful but could increase the feeling of isolation or threat, further agitating the client.
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NCLEX RN
Psychosocial Integrity
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