The nurse is caring for a client who is aggressive, demanding, and verbally abusive toward staff and visitors. The client says, "I'm getting out of here. I'm going to end it all." What immediate action should the nurse take?
1. Attempt to block the exit door.
2. Call security.
3. Attempt to administer a sedative to the client.
4. Notify the client's family.
2
Rationale 1: The nurse should not get between the client and the exit door.
Rationale 2: This client is a danger to self and perhaps to others. Security should be notified.
Rationale 3: The nurse should not approach the client.
Rationale 4: The family should be notified, but this is not the nurse's first action.
Global Rationale:
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