For a client who is agitated and has made unprovoked hostile verbal attacks on coworkers, what intervention is the priority?

For a client who is agitated and has made unprovoked hostile verbal attacks on coworkers, what intervention is the priority?

• A. De-escalate verbally using a calm, respectful tone
• B. Maintaining safety
• C. Administer a PRN sedative
• D. Call security

Answer: (B)

Maintaining safety is the priority because the first obligation in a volatile situation is to prevent harm to the client and everyone nearby. When agitation is high and hostility is evident, you must create a safe environment: clear space, keep a respectful distance, remove bystanders if needed, ensure there’s an exit path, and call for assistance as your facility requires. Only after safety is secured can you move to other steps, like de-escalation through calm, respectful communication, or, if necessary under proper protocol, pharmacologic intervention. While de-escalation and sedation are important tools, they are secondary to the immediate need to protect people from harm.

Maintaining safety is the priority because the first obligation in a volatile situation is to prevent harm to the client and everyone nearby. When agitation is high and hostility is evident, you must create a safe environment: clear space, keep a respectful distance, remove bystanders if needed, ensure there’s an exit path, and call for assistance as your facility requires. Only after safety is secured can you move to other steps, like de-escalation through calm, respectful communication, or, if necessary under proper protocol, pharmacologic intervention. While de-escalation and sedation are important tools, they are secondary to the immediate need to protect people from harm.