The nurse observes a client's anger escalating. He begins to pace the hall and shouts "You all had
better watch out.
I'm going to hurt anybody who gets in my way.". Assuming each of the following
interventions is appropriate, put them in the order in which they should occur. (Type answer in order
from first to last.)
A. Take the client to a seclusion room and administer medication.
B. Have a nurse prepare prn medication.
C. Calmly tell the client that "staff will help you control your impulse to hurt someone.".
D. Gather a show of force.
E. Remove clients from the area.
ANS: E, C, B, D, A
Rationale: The ideal sequence provides a rapid, organized response that provides safety for the other
clients and progresses from verbal limit setting to immobilization and concurrent use of medication.
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