# In a crowded emergency department waiting area, a 35-year-old visitor has been pacing for 20 minutes while waiting for news about a family member. The visitor now shouts at the triage nurse, clenches both fists, strikes the counter twice, and steps between the nurse and the only visible exit. The visitor drove the family member to the hospital 3 hours ago and has been in the department since. Speech is loud but clear and coherent, and gait is steady while pacing. The visitor is holding a half-finished bottle of regular cola from the vending machine; the skin is warm and dry. Other clients are seated nearby. The unit has a workplace-violence response code and a secondary exit behind the nurse. Complete the diagram by selecting the situation the nurse is most likely facing, 2 actions the nurse should take to address that situation, and 2 parameters the nurse should monitor in the visitor to assess whether the risk is decreasing. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=en > language: en > subject: Security Plan > category: SIPC ## Question In a crowded emergency department waiting area, a 35-year-old visitor has been pacing for 20 minutes while waiting for news about a family member. The visitor now shouts at the triage nurse, clenches both fists, strikes the counter twice, and steps between the nurse and the only visible exit. The visitor drove the family member to the hospital 3 hours ago and has been in the department since. Speech is loud but clear and coherent, and gait is steady while pacing. The visitor is holding a half-finished bottle of regular cola from the vending machine; the skin is warm and dry. Other clients are seated nearby. The unit has a workplace-violence response code and a secondary exit behind the nurse. Complete the diagram by selecting the situation the nurse is most likely facing, 2 actions the nurse should take to address that situation, and 2 parameters the nurse should monitor in the visitor to assess whether the risk is decreasing. Condition Select 1 Situational anxiety about the wait Acute alcohol intoxication Agitation from hypoglycemia Imminent physical aggression Actions to take Select 2 Keep a clear path to the secondary exit Place a hand on the visitor's shoulder Gather several staff to surround the visitor Offer juice and check a fingerstick glucose Call the workplace-violence response code Parameters to monitor Select 2 Behavioral Activity Rating Scale score Blood alcohol concentration Capillary blood glucose level Verbal threats toward staff Self-rated anxiety score on a 0–10 scale ## Explanation Pacing that escalates to shouting, clenched fists, striking objects, and blocking the exit signals imminent physical aggression rather than simple anxiety. Coherent speech, a steady gait, and having driven to the hospital argue against intoxication, and recent sugary intake with warm, dry skin argues against hypoglycemia. The nurse keeps a clear route to the secondary exit and activates the response code, then tracks the visitor's observed agitation level and verbal threats. ## In-depth explanation Quick answer Imminent physical aggression. Keep a clear path to the secondary exit and activate the workplace-violence response code. Monitor the visitor's Behavioral Activity Rating Scale score and verbal threats toward staff. Why this is correct Pacing alone suggests anxiety, but the visitor has moved from pacing to shouting, clenched fists, striking the counter, and blocking the exit. These are escalating pre-assault behaviors. Clear, coherent speech and a steady gait after driving to the hospital do not fit intoxication, and a regular cola with warm, dry skin does not fit hypoglycemia. Staff safety comes first: an escape route and a trained team response. An observer-rated agitation score and the presence of verbal threats show whether de-escalation is working. Easy analogy or mental picture When a kettle starts whistling, you step away from the spout and call for help to turn off the stove; you don't put your hand on the lid. Memory hook Fists + hitting objects + blocking the door = exit clear, code called; then watch agitation and threats. NCLEX decision rule When physical aggression is imminent, protect yourself and others first: keep an exit, call the trained team, then de-escalate from a safe distance while tracking observable behavior. Why the other choices are wrong A hand on the shoulder is meant to comfort but can be taken as a threat and invites assault. Surrounding the visitor with untrained staff looks like force and can escalate, so the trained response team should manage it. Juice with a glucose check and capillary glucose monitoring fit hypoglycemic agitation, and blood alcohol fits intoxication; the data make both unlikely. A self-rated anxiety score fits situational anxiety, depends on the visitor's cooperation, and does not track the risk of assault. References 1OSHA — Preventing Workplace Violence in HospitalsWarning signs of escalation and hospital response planning 2OSHA Hospital eTool — Workplace ViolenceMaintaining escape routes and summoning help for aggressive behavior ## Clinical scenario Scenario A pacing visitor escalates to shouting, clenched fists, and striking the counter and moves to block the only visible exit; speech is clear, gait is steady, and the visitor has been drinking regular cola. ## Key concepts - **Behavioral Activity Rating Scale (BARS)** — A 7-point observer scale used in emergency settings that rates agitation from 1 (difficult to arouse) to 7 (violent, requiring restraint). - **De-escalation** — Calm verbal and nonverbal techniques used from a safe distance to reduce agitation. - **Workplace-violence response code** — A facility alert that brings trained staff and security to an aggressive situation. ## Related questions - [Place the nursing actions in order after a client at high risk for elopement cannot be fou…](https://mymerci.kr/pages/nclex_q.php?qn_id=396362&lang=en) - [On a postpartum unit, a person in scrubs without a unit identification badge offers to tak…](https://mymerci.kr/pages/nclex_q.php?qn_id=522685&lang=en) - [In a crowded emergency department, a visitor who has waited 3 hours for news about a famil…](https://mymerci.kr/pages/nclex_q.php?qn_id=617355&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617423&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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