If a nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff, the first action to take should be to accompany the client away from the common area. By removing the client from the environment that may be triggering the agitation, the nurse can help de-escalate the situation and ensure the safety of both the client and the staff.
Placing the client in restraints should not be the first action as it can escalate the situation further and should only be used as a last resort to ensure safety when all other options have been exhausted.
Initiating observation of the client in a private room could be considered if the client's behavior continues to be a risk to themselves or others, but accompanying them away from the common area is the initial step to prevent escalation and ensure immediate safety.
Administering diazepam IM (Intramuscularly) should also not be the first action, as medication should be considered after other de-escalation techniques have been attempted, and only if the client's behavior poses a significant risk.
In summary, accompanying the client away from the common area is the most appropriate initial step to address the agitated and threatening behavior, ensuring safety and attempting to de-escalate the situation effectively.
