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).

A. Request that security guards restrain the client: This should be a last resort. Restraints can escalate a situation and should only be used when necessary for safety. The nurse should attempt to de-escalate the situation first before involving security. B. Speak to the client in a loud voice: Speaking loudly can escalate the situation, especially with someone who is already agitated. A calm, composed tone is more effective in de-escalating anxiety and aggression. C. Stand directly in front of the client: Standing directly in front of the client can be perceived as confrontational and could increase the client's aggression. It's better to maintain a safe distance and stand at an angle, not directly in front of them. D. Talk to the client using short, simple sentences: This is an appropriate response. When a client is agitated, they may have difficulty processing complex information. Using short, clear sentences can help them better understand and respond. E. Identify the client's stressors: Understanding the client’s stressors helps the nurse address the root cause of the agitation and provides an opportunity to offer support or alternative coping strategies.