NCLEX RN Practice Question

The correct action is to establish and maintain a safe environment by positioning oneself at a safe distance while using therapeutic communication techniques. Recognizing signs of escalating anger, such as pacing, clenched fists, or raised voice, allows the nurse to intervene appropriately. Maintaining a calm tone and ensuring the client's personal space can de-escalate the situation effectively and minimize the risk of harm. Other actions, such as directly instructing the client to calm down, may come across as confrontational and escalate the tension. Physical contact, such as touching the client, might increase agitation and breach their personal space. Ignoring the client entirely or failing to engage disregards the immediate risk and presents a missed opportunity to address the escalation.