The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which should be the priority nursing intervention?
A. Calmly tell the client, "Staff will help you to control your impulse to hurt others."
B. Remove other clients from the area and maintain milieu safety.
C. Gather a show of force by contacting security for assistance.
D. Calmly tell the client, "You will need to be medicated and secluded."
B
During an emergent situation on an inpatient unit, the nurse's priority action should be to keep all clients safe by removing them from the area of conflict.
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