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?

Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.