A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Choice A reason: Speaking loudly escalates tension in an agitated client, mimicking confrontation and potentially worsening yelling or pacing. De-escalation requires a calm, low tone to soothe, not provoke. This action contradicts mental health principles for managing agitation, increasing risk, so it’s not appropriate here. Choice B reason: Standing directly in front risks invading personal space, heightening agitation in a yelling, pacing client, possibly triggering aggression. A side approach maintains safety and openness, per de-escalation guidelines. This position endangers the nurse and client, making it an incorrect choice. Choice C reason: Requesting restraints assumes immediate danger without de-escalation attempts, violating least restrictive care. Yelling and pacing alone don’t justify physical control unless harm is imminent. This premature escalation skips verbal intervention, so it’s not suitable unless safety fails. Choice D reason: Short, simple sentences calm the client by reducing cognitive overload during agitation, facilitating understanding amid yelling and pacing. This de-escalation technique, part of crisis management, promotes cooperation safely. It’s a primary, effective step, making it a correct action here. Choice E reason: Identifying stressors uncovers agitation triggers (e.g., fear, pain), guiding tailored de-escalation for a yelling, pacing client. This insight informs interventions, reducing escalation risk in mental health settings. It’s a proactive, therapeutic step, correctly included in the nurse’s response.