A newly hired nurse is attending an in-service about fire safety. Which of the following actions should the nurse take first in the event of a fire?

A. Place the client in restraints: Physical restraints are used only as a last resort when the client poses an immediate danger to self or others. In delirium, restraints can worsen agitation, increase confusion, and elevate the risk of injury or further cognitive decline. Nonpharmacologic de-escalation and environmental modifications are preferred initial interventions.

B. Offer the client a variety of activities to choose from: Clients with delirium have impaired attention, fluctuating levels of consciousness, and reduced ability to process multiple stimuli. Providing numerous choices can increase confusion and cognitive overload. Care should focus on structured, simple activities rather than offering multiple options.

C. Communicate with the client using simple, direct statements: Delirium impairs cognition, attention, and comprehension, making complex communication difficult. Using short, clear, and direct statements helps reduce misinterpretation and supports orientation. Consistent, simple communication decreases anxiety and promotes better understanding in hallucinations.

D. Limit how often the client's partner can visit: Familiar individuals can provide reassurance, assist with reorientation, and decrease anxiety in clients with delirium. Restricting visits may increase confusion and agitation. Encouraging the presence of trusted family members often supports cognitive stabilization and emotional comfort.

A. Providing a ham and cheese sandwich to a client who follows a kosher diet: Kosher dietary laws prohibit pork and require specific food preparation. Giving a ham sandwich directly violates the client’s religious dietary restrictions and requires immediate correction and staff education to respect cultural and religious practices.

B. Giving peanut butter to a client who was prescribed a mechanical soft diet: A mechanical soft diet includes foods that are easy to chew and swallow. While crunchy peanut butter would be restricted, smooth peanut butter is typically allowed as it does not require significant mastication.

C. Offering ginger ale to a client who is a member of the Mormon faith: Ginger ale is nonalcoholic and caffeine-free options are usually available. Serving ginger ale is generally consistent with Mormon dietary restrictions, which prohibit alcohol and caffeinated beverages, so this does not require intervention.

D. Serving ice cream to a client who prescribed a full-liquid diet: Ice cream is considered a full-liquid food and is consistent with this diet order. It does not violate dietary guidelines, so no intervention is required.