A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

A. Establish a client relationship. While building a therapeutic relationship is important, the priority in this situation is addressing the immediate behavior. The client has just attacked someone, and the nurse must first set clear boundaries to ensure safety for both the client and others in the environment before any relationship-building can take place. B. Set behavioral limits for the client. This is the first priority. In situations where aggressive or violent behavior has occurred, it is crucial to establish clear, firm, and immediate behavioral limits. This helps the client understand what is acceptable behavior and ensures a safe environment for everyone. Setting limits also provides structure and helps prevent further aggressive actions. C. Explain to the client that the behavior was unacceptable. While it is important to communicate that aggressive behavior is unacceptable, it should be done after establishing safety and setting limits. The focus should initially be on maintaining a safe environment and preventing further aggression. D. Explore the truth of the client's statements. Exploring the client's statements is part of the therapeutic process, but it is not the first priority in this situation. The nurse must first address the immediate concern of safety and establish appropriate boundaries before engaging in deeper exploration of the client's thoughts or statements.