A nurse is caring for a client who has a history of aggressive behavior and is currently pacing back and forth while clenching their fists. Which action should the nurse take first to ensure safety?
Approach the client and use a calm, nonthreatening tone to engage them.
Apply restraints to prevent potential harm to the client or others.
Remove certain staff and other clients from the area to ensure safety.
Call for security personnel to stand by in case of an emergency.
The best initial action is to calmly approach the client and speak in a nonthreatening tone to de-escalate the situation. This approach allows the nurse to assess the client's level of agitation while employing therapeutic communication to reduce aggression. Calling for security prematurely might further agitate the client, escalating the situation unnecessarily. Restraining the client should only be a last resort after other noninvasive methods, such as communication, have failed. Removing certain people from the area may be part of a broader safety strategy, but it does not directly address the client's immediate needs or behavior.
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NCLEX RN
Psychosocial Integrity
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