medium · NCLEX-RN Psychosocial Integrity

A client on the inpatient unit, Riley, age 34, is pacing rapidly with clenched fists and shouting at other clients.

Which nursing intervention is the safest immediate response to prevent escalation to violence?

  1. Approach the client immediately and place a hand on their shoulder to offer comfort.
  2. Ask the client 'Why are you acting so aggressively toward people who want to help you?'
  3. Maintain a clear path to the exit for the staff and the client while speaking in a calm, low voice.
  4. Gather several staff members to stand closely around the client to demonstrate a 'show of force.'

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