A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

Choice A reason: Identifying the client’s feelings underlying the delusions is therapeutic. Delusions often mask fear, anxiety, or insecurity. By focusing on the emotions rather than the false belief, the nurse validates the client’s experience without reinforcing the delusion. This approach builds trust and supports emotional regulation.

Choice B reason: Telling the client that the delusion is not real is ineffective and can increase defensiveness. Clients with schizophrenia often lack insight, and direct confrontation may escalate agitation or mistrust.

Choice C reason: Reinforcing the delusion is harmful. It strengthens false beliefs and impedes recovery. Nurses must avoid validating delusional content while still supporting the client’s emotional needs.

Choice D reason: Helping the client ignore events that trigger delusions is unrealistic. Triggers cannot always be avoided, and ignoring them does not teach coping strategies. Instead, nurses should help clients develop grounding techniques and reality-based coping skills.

Choice A reason: Offering the client a PRN dose of lorazepam is appropriate because benzodiazepines are often prescribed for acute agitation and anxiety. Administering medication can help de-escalate the situation, reduce the risk of violence, and restore calm. This intervention directly addresses the client’s agitation and promotes safety for both the client and others.

Choice B reason: Asking open-ended questions during an episode of acute agitation is not appropriate. Open-ended questions require thought and elaboration, which can increase frustration and escalate aggression. In crisis situations, communication should be simple, direct, and focused on safety rather than exploration.

Choice C reason: Standing directly in front of the client is unsafe because it places the nurse in a vulnerable position if the client becomes physically aggressive. The nurse should maintain a safe distance and stand at an angle to reduce the risk of harm.

Choice D reason: Moving others away from the client is correct because it protects the safety of the group. Removing potential targets of aggression reduces the risk of injury and helps de-escalate the environment. This is a critical safety measure in managing violent behavior.

Choice E reason: Speaking in an aggressive tone of voice is inappropriate because it escalates tension and may provoke further aggression. The nurse should use a calm, firm, and non-threatening tone to de-escalate the situation.