Difficulty: Medium
Average Score: 70%
Simulated
A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?
Correct answer
C
Rationale
The correct answer is C: Acknowledge the client's emotions. This is the first action the nurse should take because it helps to establish a therapeutic relationship and demonstrates empathy towards the client's feelings. Acknowledging the client's emotions can help de-escalate the situation and show the client that their feelings are being heard and validated. It also opens up communication channels for further assessment and intervention. Administering a sedative (choice A) should not be the first action as it does not address the underlying emotional distress. Performing a debriefing (choice B) with the staff can wait until the immediate crisis is managed. Placing the client in restraints (choice D) should be a last resort and used only if the client poses a serious threat to themselves or others.