A licensed practical nurse (LPN) is making a home health visit to a 34-year-old man on postoperative day 3 following an appendectomy. His wife states he has been "not himself" since yesterday. The client is oriented to person only, has a fluctuating level of alertness, and intermittently states that insects are crawling on the walls. Earlier today he was calm and cooperative, but he now appears restless, is pacing near the front door, and his speech is becoming louder. There is a television playing loudly and two family members are asking him questions at the same time. Vital signs: temperature 100.8°F (38.2°C), pulse 108 bpm, respirations 22/min, blood pressure 142/88 mmHg. Which action should the nurse take first?
- Apply a soft wrist restraint to keep him from wandering out the door.
- Turn off the television, ask family to step back, and speak calmly to reduce stimulation.
- Turn up the lights, ask him direct orientation questions, and encourage him to walk more.
- Firmly remind the client several times that the insects are not real.