A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

A: Speaking loudly can escalate the patient’s agitation and is not recommended. A calm and soothing tone is more effective. B: Ensuring adequate space between the nurse and the patient helps maintain safety and reduces the risk of physical harm. C: Approaching the patient in a calm manner helps de-escalate the situation and provides reassurance to the patient. D: Locking the patient in their room can increase their agitation and feelings of isolation. It should only be considered if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed. E: Providing a detailed explanation of unit policies is not appropriate in the moment of crisis. The focus should be on immediate de-escalation and ensuring safety.