NCLEX RN Practice Question

The correct answer is to engage the client in a discussion using a neutral and steady tone, while creating a safe distance between the nurse and the client. This approach prioritizes safety by keeping physical distance and addressing the client’s distress through verbal interaction, which can help de-escalate tension. The use of a calm voice without provoking or challenging the individual can prevent the situation from escalating further.

Calling for security as the first step is not ideal unless the situation poses an immediate threat that cannot be mitigated through de-escalation techniques. Offering restrictive interventions prematurely, such as restraint, can worsen the client’s agitation and should be avoided unless there is an imminent risk of harm. Asking detailed questions about the client’s anger at the height of agitation might be misinterpreted as confrontational, potentially escalating the scenario further.