A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?
Explanation & Rationale
Choice A reason: Administering medication may be necessary, but it is not the first step. Pharmacologic intervention should follow a thorough assessment and attempts at de-escalation through therapeutic communication. Choice B reason: Debriefing is a post-incident action. It helps staff process the event and improve future responses but does not address the immediate needs of the client in crisis. Choice C reason: Acknowledging the client's emotions is a de-escalation technique that helps build rapport and reduce agitation. It is a therapeutic and non-invasive first step that prioritizes safety and emotional regulation. Choice D reason: Restraints are a last resort and should only be used when the client poses an immediate danger to themselves or others and other interventions have failed. Using restraints prematurely can escalate the situation and violate ethical standards.