A nurse is caring for a client who has a history of aggressive behavior and is currently showing signs of escalating agitation, including clenched fists and pacing the room. What is the BEST initial action the nurse should take?
Step back and observe the client closely to evaluate the need for further intervention.
Prepare physical restraints in case the client becomes physically aggressive.
Contact security to ensure the safety of the healthcare team.
Speak with the client using a calm, non-threatening tone and acknowledge their feelings.
The correct answer is to adopt an early intervention to de-escalate the client's agitation in a safe manner. Speaking calmly and acknowledging the client's distress lowers the agitation level and demonstrates empathy, reducing the likelihood of violence. Close observation or additional security measures may be necessary but should follow attempts to de-escalate the situation. Restraining or isolating the client should be a last resort and used only when there is an imminent threat of harm. Focusing solely on observing without action risks escalation, and prematurely involving security can intensify the situation unnecessarily.
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NCLEX RN
Psychosocial Integrity
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