A Patient Who Was Responding to Auditory Hallucinations Earlier in the Morning

Multiple Choice

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should

A) make sure there is adequate physical space between the nurse and patient.
B) move into a position that places the patient close to the door.
C) maintain one arm's length distance from the patient.
D) begin talking to the patient about appropriate behavior.