Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

The correct answer is choice B. Erotomanic.

Choice A rationale:

Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.

Choice B rationale:

Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.

Choice C rationale:

Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.

Choice D rationale:

Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.