Difficulty: Medium
Average Score: 80%
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 in this situation because it helps establish a therapeutic relationship and shows empathy towards the client's feelings. Acknowledging the client's emotions can help de-escalate the situation and allow the client to feel heard and understood. Administering a sedative medication (A) should not be the first action as it may escalate the situation further. Performing a debriefing with staff (B) is important but should come after ensuring immediate safety. Placing the client in restraints (D) should be a last resort and only used if all other de-escalation techniques have failed.