A nurse is caring for a client who has delirium.
Which of the following findings should the nurse expect?

Choice A rationale

While exploring the client's relationship with their partner is important for understanding their grief, immediately asking for details might feel intrusive or overwhelming shortly after a significant loss. The nurse should first acknowledge the client's feelings before delving into specifics of the relationship.

Choice B rationale

"Grief affects everyone differently; your feelings are valid" is an empathetic and validating response that acknowledges the client's unique experience and normalizes their emotions. It provides support and reassurance without minimizing their loss or telling them how they should feel, fostering trust and open communication.

Choice C rationale

Suggesting the client "stay busy to take your mind off things" can be dismissive of their grief and may prevent them from processing their emotions in a healthy way. While distraction can be helpful at times, avoiding grief entirely is not a constructive coping mechanism and can prolong the healing process.

Choice D rationale

Recommending a bereavement support group is a helpful suggestion for long-term support; however, immediately after the loss, the client may not be ready to engage in a group setting. The nurse should first focus on providing immediate emotional support and then suggest resources like support groups when the client is more ready.

Choice A rationale

Placing a client in seclusion involves isolating them in a safe area to prevent harm to themselves or others. While seclusion may be necessary if de-escalation fails and the client poses an immediate threat, it should not be the first action. Less restrictive interventions should be attempted first to address the client's agitation and potential aggression.

Choice B rationale

Verbal de-escalation techniques are the initial and least restrictive interventions for managing a client who is threatening harm. These techniques involve using calm communication, active listening, empathy, and setting clear limits to help the client regain control and reduce their agitation without resorting to more restrictive measures.

Choice C rationale

Offering medication to calm the client may be considered if verbal de-escalation is ineffective and the client's agitation escalates. However, it is not the first action. A thorough assessment of the client's condition and the reason for their agitation should precede medication administration, and it should be used in conjunction with other de-escalation strategies.

Choice D rationale

Arranging for a critical incident debriefing with the staff is an important step after a crisis situation has been resolved to review the event, support staff, and identify areas for improvement. However, it is not the immediate action to take when a client is actively threatening harm to staff. The immediate priority is to ensure the safety of the client and staff.