Difficulty: Medium
Average Score: 84%
Simulated
A client turns over a table in the day room of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?
Correct answer
C
Rationale
The immediate priority is the safety of all clients and staff. The situation requires a team response to safely de-escalate the client and prevent violence. Approaching the client alone (D) is unsafe and could provoke an attack. A "show of force" (B) is likely to be perceived as threatening and may further escalate aggression. Offering observational feedback (A) is a de-escalation technique, but it is not the first step when there is an imminent threat of violence; ensuring sufficient staff support is required before attempting verbal intervention.