A nurse enters a client's room and sees a visitor threatening the client. The nurse questions the visitor in a nonthreatening manner. The visitor begins to threaten the nurse. What should the nurse do in this situation?
1. Keep a safe distance from the visitor.
2. Yell for another nurse to assist with the visitor.
3. Leave the room.
4. Threaten the visitor with assault charges.
1
Rationale 1: The nurse should recognize threatening behavior and keep a safe distance from the visitor exhibiting the behavior.
Rationale 2: The nurse should obtain assistance but yelling may increase the visitor's aggression.
Rationale 3: The nurse should not leave the client unless it is absolutely necessary to obtain assistance.
Rationale 4: Threatening the visitor with assault charges may further escalate the situation.
Global Rationale:
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