A Patient Who Has Been Seen Responding to Auditory Hallucinations

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist,saying,"Back off,bitch!" and then goes into the day room.Which intervention would be most important to undertake before the nurse follows the patient into the day room?

A) Contact the patient's physician to obtain an order for seclusion.
B) Review the patient's history for clues about his risk of violence.
C) Assure that adequate staff are available and nearby for backup.
D) Check for orders for PRN medication and prepare a sedative.