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: Standing directly in front of the client is unsafe. This positioning can be perceived as confrontational and may escalate the client’s agitation. It also places the nurse at risk of harm if the client becomes aggressive. The therapeutic approach is to maintain a safe distance and stand at an angle, which reduces perceived threat and allows for a safer exit if needed. Choice B reason: Identifying the client’s stressors is an appropriate intervention. Understanding what triggered the yelling and pacing helps the nurse address the root cause of agitation. This approach promotes de-escalation by validating the client’s feelings and working collaboratively to reduce distress. It is consistent with therapeutic communication and crisis intervention strategies. Choice C reason: Requesting security guards to restrain the client is not an immediate or appropriate first-line intervention. Physical restraint should only be used as a last resort when the client poses imminent danger to themselves or others and all other de-escalation techniques have failed. In this scenario, the nurse should first attempt verbal and environmental interventions before escalating to restraint. Choice D reason: Talking to the client using short, simple sentences is highly effective. Clients who are agitated may have difficulty processing complex information. Clear, concise communication reduces confusion and helps the client focus on calming down. This technique is a cornerstone of de-escalation strategies in mental health care. Choice E reason: Speaking to the client in a loud voice is counterproductive. A loud tone can be perceived as aggressive or threatening, which may escalate agitation further. The nurse should instead use a calm, steady, and reassuring tone to promote safety and trust.