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 an agitated client may escalate the situation by invading personal space and increasing perceived threat. Choice B reason: Restraints should only be used as a last resort when there is imminent danger. De-escalation techniques should be attempted first. Choice C reason: Speaking loudly can increase agitation. A calm, low tone is preferred to reduce tension. Choice D reason: Identifying stressors helps the nurse understand triggers and tailor de-escalation strategies effectively. Choice E reason: Using short, simple sentences reduces cognitive overload and promotes clarity during agitation.