A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure.
The client informs the nurse that they do not want to have the procedure.
Which of the following actions should the nurse take?

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

The most important action for the nurse to take first is to establish a rapport and foster trust with the client. This is represented by option d.

Here's why the other options are not the best first steps:

• a. Implement continuous one-to-one observation:While monitoring safety is crucial,it does not address the immediate emotional need of the client,who has just endured a traumatic experience.Building trust first can facilitate open communication and help the client feel safe enough to express their feelings and needs.
• b. Ask the client to sign a no-suicide contract:No-suicide contracts have limited effectiveness and can even be harmful by putting undue pressure on the client.Building trust and a collaborative plan are more effective ways to manage safety.
• c. Encourage the client to participate in group therapy:Group therapy can be beneficial,but it's not appropriate as the immediate first step.Individualized attention and establishing a secure relationship are crucial at this early stage.

Therefore, establishing rapport and fostering trust is the most important action for the nurse to take first. This will create a safe space for the client to openly express their thoughts and feelings, allowing the nurse to assess their needs and develop a proper care plan.

Remember, this is just the first step. Subsequent actions will involve a comprehensive assessment, safety measures, and collaborating with the client and other healthcare professionals to develop a personalized treatment plan.