A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

Speak with a very loud voice so that the patient can hear.

Ensure there is adequate space between nurse and patient.

Approach the patient in a calm manner.

Ensure the patient is safely locked in their room.

Give the patient a detailed explanation of all unit policies.