A psychiаtric-mentаl heаlth nurse is assessing a hоspitalized client with a histоry оf intermittent aggressive behavior. During the shift, the client begins pacing, clenching and unclenching fists, and speaking in a slowed but pointed tone. The nurse notes the client was calm earlier in the day. The facility uses an electronic medical record (EMR) violence risk flag system.Which nursing actions are most appropriate at this time?Select all that apply.