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

Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.

Choice B rationale

Discouraging visitation from the client's family can increase feelings of isolation and anxiety. Family support can provide comfort and reassurance, which are beneficial for clients with delirium.

Choice C rationale

Keeping the client's room dark at night can disorient them further. Maintaining a well-lit environment helps with orientation and reduces the likelihood of hallucinations or worsening confusion.

Choice D rationale

Providing a high-stimulation environment can increase agitation and confusion. A calm, low-stimulation environment helps minimize stress and can aid in the recovery of clients with delirium.

Choice A rationale

Splitting is a defense mechanism where a person sees things in black-and-white, without the capacity to recognize nuances or integrate good and bad qualities together.

Choice B rationale

Suppression is a conscious decision to delay dealing with stressors or emotions until a later time, as the client does by focusing on their son’s wedding before addressing their health.

Choice C rationale

Reaction formation involves behaving in a way that's opposite to one's true feelings, which does not align with the client's expressed actions.

Choice D rationale

Projection is attributing one's own thoughts, feelings, or impulses to another person, not evident in the client's behavior.