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

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 day room. While following the patient into the day room, the nurse should do which of the following?

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 behaviour