# In a crowded emergency department, a visitor who has waited 3 hours for news about a family member has been pacing near triage. The visitor begins shouting at the triage nurse, clenches both fists, steps between the nurse and the only visible exit, and strikes the counter. No weapon is seen, and the visitor answers questions about the date and place correctly. Several clients are seated nearby. The unit has a workplace-violence response code, and a secondary exit is 4 m behind the nurse. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617355&lang=en  
> language: en  
> subject: Security Plan  
> category: SIPC

## Question

In a crowded emergency department, a visitor who has waited 3 hours for news about a family member has been pacing near triage. The visitor begins shouting at the triage nurse, clenches both fists, steps between the nurse and the only visible exit, and strikes the counter. No weapon is seen, and the visitor answers questions about the date and place correctly. Several clients are seated nearby. The unit has a workplace-violence response code, and a secondary exit is 4 m behind the nurse. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Verbal frustration with low assault risk
Imminent risk of physical assault
Acute panic attack in a distressed visitor
Active armed-intruder threat

Actions to take

Select 2
Gather several staff to surround the visitor
Keep a clear path to the secondary exit
Offer to talk with the visitor in a private room
Activate the workplace-violence response code
Initiate a facility lockdown for an intruder

Parameters to monitor

Select 2
Visitor's pulse and breathing rate
Visitor's voice volume and posture
Current triage wait time
Bystander distance from the visitor
Visitor's orientation to time and place

## Explanation

Shouting with clenched fists, striking an object, and blocking the nurse's exit are escalation behaviors that signal imminent risk of assault, beyond ordinary frustration; there is no weapon to suggest an armed-intruder event, and the visitor is oriented. The nurse keeps an escape route open and activates the workplace-violence response. Voice and posture show whether de-escalation is working, and bystander distance shows whether others remain in harm's way.

## In-depth explanation

Quick answer
Imminent risk of physical assault. Take action: keep a clear path to the secondary exit and activate the workplace-violence response code. Monitor: visitor's voice volume and posture, and bystander distance from the visitor.

Why this is correct
Striking objects, clenched fists, and moving to block an exit are late warning signs on the escalation continuum. The nurse's first job is personal and bystander safety: preserve an exit and bring trained responders early rather than after an assault. Once safe, one calm staff member may continue de-escalation. Escalation behaviors and bystander proximity are the parameters that show whether the danger is falling.

Easy analogy or mental picture
Think of a kettle that has started to whistle and rattle its lid: step back from the spout, keep the door open behind you, and call for the person trained to take it off the stove.

Memory hook
FISTS + BLOCKED EXIT = EXIT and ALERT; watch BODY LANGUAGE and BYSTANDERS.

NCLEX decision rule
When behavior shows imminent violence, safety of staff and bystanders comes first: preserve an escape route and summon the response team before attempting further communication or physical control.

Why the other choices are wrong
Ordinary frustration does not include blocking an exit and striking objects. A panic attack causes fear and autonomic symptoms rather than threatening posture, so pulse and breathing rate track the wrong problem. No weapon is seen, so a lockdown for an armed intruder overreacts and diverts resources. Surrounding an agitated person without a trained response team is a show of force that can provoke assault. A private room isolates the nurse with an aggressive person. Wait time drives frustration but does not measure current danger, and orientation screens for delirium, which the visitor does not show.

References
1OSHA Preventing Workplace Violence in HealthcareRecognition of escalating behavior and workplace-violence prevention programs in healthcare
2OSHA Hospital Workplace Violence eToolHospital staff safety measures: keeping exits clear, summoning help, and avoiding isolation with aggressive visitors

## Clinical scenario

Emergency department
A visitor escalates from pacing to shouting, fist clenching, blocking the only visible exit, and striking the counter while other clients sit nearby.

## Key concepts

- **Escalation continuum** — Progression from anxiety to verbal aggression to physical threat; late signs include striking objects and blocking exits.
- **Workplace-violence response code** — A facility alert that brings trained staff and security to a threatening situation.
- **Escape route** — An unobstructed path the nurse keeps between self and an exit when a person is agitated.

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