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A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?

A.

Select a quiet location to talk to the client while remaining visible to staff members.

B.

Give the client several clear options.

C.

Observe the client and the situation.

D.

Respect the client's personal space.

Answer and Explanation

The Correct Answer is C

Rationale: 

 

A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment. 

 

B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response. 

 

C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps. 

 

D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.

 


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