A Patient Has Been Responding to Auditory Hallucinations Throughout the Day

Multiple Choice

A patient has been responding to auditory hallucinations throughout the day. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should:

A) make sure adequate physical space exists between the nurse and the patient.
B) move into a position that allows the patient to be close to the door.
C) maintain one arm's length distance from the patient.
D) sit down in a chair near the patient.