What is the nurse's first action when a client becomes extremely agitated and aggressive?

In situations where a client becomes extremely agitated and aggressive, the priority is to ensure the safety of all individuals involved, including the agitated client, other clients, and staff. Thus, the first action a nurse should take is to remove other clients from the area. This action helps prevent potential harm or escalation of the situation, allowing the nurse to focus on managing the aggressive client without the presence of others who might be at risk or exacerbating the aggression.

Ensuring a safe environment is critical in psychiatric nursing practice, as it allows for further interventions to be implemented without distraction or additional danger to non-involved individuals. Once safety is secured, the nurse can then consider other actions, such as calming the client verbally or calling for assistance. However, the immediate step to protect everyone in the vicinity takes precedence.