A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

A. Apply restraints according to the facility's standing order: Restraints should never be applied based on a standing order. Each use of restraints requires a specific, immediate provider order following a thorough assessment of the situation. B. Obtain a PRN prescription for restraints from the provider: PRN (as-needed) orders for restraints are not appropriate. Restraints must be ordered specifically when the need arises, after evaluating less restrictive measures. C. Stand in front of the client to block them from others in the room: Standing directly in front of a combative client can escalate the situation and put the nurse at risk of injury. Maintaining a safe distance and using de-escalation techniques are safer strategies. D. Ensure there are enough staff members available for assistance: Ensuring sufficient staff presence is critical when a client becomes combative. It helps ensure the safety of the client, other clients, and staff members, and allows for a coordinated response if physical intervention becomes necessary.