The nurse observes a client's escalating anger.The client begins to pace the hall and shouts,"You all better watch out.I'm going to hurt anyone who gets in my way." Which is the priority nursing intervention?
A)Calmly tell the client,"Staff will help you to control your impulse to hurt others."
B)Remove other clients from the area and maintain milieu safety.
C)Gather a show of force by contacting security for assistance.
D)Calmly tell the client,"You will need to be medicated and secluded."

Question

Quizplus · Accepted Answer

The priority nursing intervention is to ensure the safety of all individuals in the area. Therefore, removing other clients from the area and maintaining milieu safety is the best option. The nurse should also contact security for assistance if necessary. Calmly telling the client staff will help them control their impulse or threatening to medicate and seclude the client might escalate the situation further.

The Nurse Observes a Client's Escalating Anger