A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?

Choice A rationale

Light therapy can be an effective treatment for certain conditions, like seasonal affective disorder, but it typically does not require informed consent unless it's experimental or has significant risks.

Choice B rationale

Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial.

Choice C rationale

Participating in a group exercise program generally does not require informed consent. These activities are typically part of routine care and considered low risk.

Choice D rationale

Attending a cognitive behavioral therapy class usually does not require informed consent beyond the initial agreement to participate in therapy. These sessions are standard parts of mental health care.

Choice A rationale

Referring the client for social services support is important but not the first action in addressing immediate safety.

Choice B rationale

Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action.

Choice C rationale

Reinforcing coping skills is valuable but secondary to ensuring the client's safety.

Choice D rationale

Encouraging use of personal support systems is helpful but not the first priority in addressing immediate risk. .