A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?

Choice A reason: Assisting the client in prioritizing decisions is important in crisis intervention, but it is not the first priority. Before helping the client make decisions, the nurse must ensure that the client is safe and not at risk of harming themselves. Decision-making can only be effective once immediate safety is established.

Choice B reason: Determining whether the client is at risk for self-harm is the priority because the client is in acute distress and has expressed confusion and inability to think clearly. These are red flags for potential self-harm or suicidal ideation. Safety is always the first priority in crisis situations, and assessing risk ensures that urgent interventions can be implemented if needed.

Choice C reason: Helping the client identify personal strengths is a supportive intervention that can aid in coping, but it is not the immediate priority. This step comes after ensuring that the client is safe and stable.

Choice D reason: Identifying a support person to notify and take the client home is helpful for providing external support, but it is secondary to assessing immediate risk of self-harm. Without first ensuring safety, this intervention may not adequately address the client’s urgent needs.

Choice A reason: Canceling the appointment delays necessary care and is not appropriate unless safety cannot be managed.

Choice B reason: Clients experiencing mania have short attention spans and difficulty processing complex information. Explaining the procedure in simple, clear terms is the most effective approach.

Choice C reason: A thorough explanation may overwhelm the client and increase agitation due to their inability to focus.

Choice D reason: Calling security preemptively is unnecessary unless there is a history of violence. It may escalate the situation and increase paranoia.