A 52-year-old man with a history of depression presents to the emergency department accompanied by his adult children who report that the client is behaving differently than during past episodes. They report he has withdrawn and refuses to speak to anyone. He sits in his recliner all day and stares straight ahead. He has not eaten in two days. His son tried to put a glass of juice in his hand and lift it to his mouth, and the client kept his hand up to his mouth but did not take a drink. His mental status exam is significant for alogia and lack of movement except for purposelessly keeping his right arm up in the air. When the examiner attempts to lower the patient's arm, the client demonstrates slight, even resistance. His only current medication is sertraline 200 mg per day. Which listed action is the best initial step?

Choice A reason: The client exhibits classic signs of catatonia, including waxy flexibility (flexibilitas cerea), mutism, and alogia. An intravenous or intramuscular lorazepam challenge is the gold-standard diagnostic and initial therapeutic step. A positive response, characterized by a rapid reduction in catatonic symptoms, confirms the diagnosis and guides subsequent high-dose benzodiazepine therapy. Choice B reason: Low-dose risperidone is generally avoided as an initial step because antipsychotics can potentially worsen catatonic symptoms or precipitate neuroleptic malignant syndrome in a catatonic patient. While second-generation antipsychotics are sometimes used later in treatment, they are not the first-line intervention for acute catatonia where benzodiazepine responsiveness must be assessed. Choice C reason: Tapering and discontinuing sertraline is not the best initial action because the client's current presentation is an acute behavioral emergency requiring immediate intervention. While SSRIs like sertraline are not indicated for catatonia, simply removing the medication does not address the underlying catatonic state or the immediate risks of dehydration and malnutrition present. Choice D reason: Prescribing daily extended-release bupropion is inappropriate for an acute catatonic episode. Bupropion is an antidepressant that increases norepinephrine and dopamine levels, but it lacks the rapid GABAergic effect required to break catatonia. Initiating such therapy would delay necessary treatment and fails to address the diagnostic need for a lorazepam challenge.