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 in a loud voice can escalate agitation in a client who is yelling and pacing, as it may be perceived as confrontational. Agitation, often linked to anxiety or psychosis, responds better to calm, non-threatening communication to reduce overstimulation and promote de-escalation. Choice B reason: Standing directly in front of the client can be perceived as threatening, increasing agitation. Personal space is critical in de-escalation, as close proximity may trigger a fight-or-flight response in a client experiencing heightened arousal, potentially leading to aggressive behavior. Choice C reason: Short, simple sentences are effective for communicating with an agitated client, as they reduce cognitive overload. Agitation impairs processing, and clear, concise communication helps convey calm and understanding, facilitating de-escalation and reducing the risk of escalation in a stressful situation. Choice D reason: Requesting restraints is a last resort, as they can escalate agitation and cause trauma. Non-restrictive de-escalation techniques, like verbal calming, are prioritized to respect autonomy and safety. Restraints are only justified if the client poses an immediate danger to self or others. Choice E reason: Identifying stressors helps address the root cause of agitation, which may stem from environmental, psychological, or physiological triggers. Understanding these allows tailored interventions, such as reducing stimuli or addressing unmet needs, to de-escalate the client effectively and prevent further escalation of behavior.