A nurse in an inpatient mental health facility is caring for a client who is showing indications of becoming violent. Which of the following actions should the nurse take?

A. Call security guards to the scene for a show of force: Calling security may escalate the situation, especially if the client is already showing signs of agitation. This could increase fear or aggression, making it harder to de-escalate the client. A calm and supportive approach is more effective. B. Escort the client to a secluded area to speak privately: Escorting the client to a secluded area may increase feelings of isolation or entrapment, potentially worsening the situation. It is better to maintain an open, non-threatening environment for communication and de-escalation. C. Offer the client several options for a time-out period: Offering choices, such as a time-out, helps the client feel some control over the situation, which can reduce agitation. This strategy fosters cooperation while addressing the need for the client to calm down in a safe space. D. Place the client in restraints before they escalate further: Restraints should be a last resort and only used if the client poses an immediate danger to themselves or others. Using restraints prematurely can increase aggression and escalate the situation, so other de-escalation techniques should be tried first.