A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.

Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.

Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.

Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.

Choice A reason: Responding to family requires clinical judgment and communication skills beyond AP scope. Nurses handle this in mass casualty for accuracy.

Choice B reason: Triage prioritization needs nursing assessment skills, not AP training. Determining care order is a licensed responsibility in emergencies like this.

Choice C reason: Cleaning and dressing wounds involves sterile technique and assessment, outside AP scope. Nurses perform this in mass casualty settings.

Choice D reason: Taking vital signs is within AP scope, providing data for nurse triage. It’s a routine task, safely assigned in a mass casualty event.