A patient is being treated on the mental health unit for an anxiety disorder. The patient approaches the nurse and reports feeling dizzy and weak, with a sensation of a racing heart. The nursing care plan includes interventions of imagery exercises and as-needed lorazepam (Ativan) for symptoms of anxiety. What should the nurse do first?

Choice A reason: The 'thinking/content of thought' section of the Mental Health Status Examination assesses the logical process of thought, presence of delusions, obsessions, and preoccupations.

Choice B reason: 'Memory' assesses the person's ability to recall past events, which is not directly related to their current thought content.

Choice C reason: 'Judgment' evaluates the ability to make reasoned decisions, which, while important, is distinct from the content of thought.

Choice D reason: 'Speech and the ability to communicate' assesses the clarity, relevance, and coherence of speech, not the internal thought process.

Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.

Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.

Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.

Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.