NCLEX RN Practice Question

The correct answer is to ensure safety by removing items that could be used as weapons. This is a key component of de-escalation techniques in managing potentially violent clients. These behaviors—pacing, clenched fists, and loud speech—are warning signs of escalating aggression and physical outbursts. By first removing potential weapons, the nurse minimizes the immediate risk of harm to the client, staff, or others. While 'Use a calming tone and discuss their concerns' is a recommended intervention in non-violent situations, it is not the priority action when there is an active risk of violence. For 'Inform the client that they need to stop pacing,' this may escalate agitation and is not recommended. Lastly, 'Offer the client medication to reduce stress' can be an option after addressing immediate safety guarantees, but medications take time to work and are not the first step in managing imminent violence.