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)

Introduction: The management of acute agitation requires de-escalation techniques that prioritize personal space and clear, non-confrontational communication to prevent the escalation of behavioral distress into physical violence. A. Standing directly in front of the client can be perceived as confrontational or threatening, which may escalate the client's agitation. The nurse should stand at an angle and maintain a distance of at least two arm lengths to respect the client's personal space and provide a clear exit path for both parties. B. Requesting security to restrain the client is a premature and highly restrictive intervention. Restraints should only be used as a last resort when the client is an immediate physical danger. Initial interventions should focus on verbal de-escalation and environmental management to calm the client without the use of force. C. Talking to the client using short, simple sentences is an effective de-escalation strategy. An agitated individual often has a decreased ability to process complex information. Clear, concise communication reduces the cognitive load and helps the client understand instructions or questions, which can help lower their overall anxiety level. D. Identifying the client's stressors allows the nurse to address the underlying cause of the agitation. By understanding what triggered the yelling and pacing, the nurse can intervene directly to resolve the conflict or provide comfort, which is a more sustainable and therapeutic approach than simply managing the outward behavior. E. Speaking to the client in a loud voice is likely to increase the client's agitation. To de-escalate the situation, the nurse should maintain a calm, low, and steady tone of voice. This non-threatening vocal quality can help the client model their own behavior after the nurse, potentially leading to a calmer state.