A nurse observes a client pacing the room, speaking loudly, and clenching their fists. What is the most appropriate first action to address the situation?
Initiate physical restraint to prevent harm to the client or others.
Exit the room to allow the client time to calm down on their own.
Use authoritative language to assert control over the situation.
Maintain a safe distance and speak to the client in a neutral tone to assess their level of agitation.
The correct answer is to remain at a safe distance and use a neutral tone to engage with the client. These actions help de-escalate the situation by avoiding any behaviors that might be perceived as threatening, ensuring the nurse can assess the level of agitation while maintaining personal safety. Adopting an authoritative tone or immediately restraining the client can escalate the situation unnecessarily. Similarly, leaving the room could make the client feel abandoned and may increase their agitation.
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NCLEX RN
Psychosocial Integrity
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