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

Choice A reason: Developing a statement about health alterations is part of documentation but not the first action. Stress impacts the hypothalamic-pituitary-adrenal axis, increasing cortisol, and requires assessment first to identify cognitive or emotional changes, ensuring targeted interventions rather than premature documentation of unassessed conditions. Choice B reason: Conducting a mental status exam first assesses cognitive, emotional, and behavioral changes due to stress, which activates the amygdala and elevates cortisol, impairing prefrontal cortex function. This identifies severity (e.g., anxiety, impaired concentration), guiding appropriate interventions like counseling or relaxation techniques to address physiological and psychological stress effects. Choice C reason: Establishing goals is important but secondary to assessment. Stress affects neuroendocrine pathways, increasing catecholamines and cortisol, which impair cognition. Without assessing mental status, goals may be misaligned, as understanding the client’s stress-related symptoms is critical to setting realistic, effective short- and long-term objectives. Choice D reason: Teaching stress-reduction techniques is effective but not the first step. Stress elevates sympathetic activity, increasing heart rate and cortisol. Without assessing mental status, techniques may be inappropriate. A mental status exam identifies specific stress manifestations, ensuring tailored interventions to reduce physiological and psychological stress responses.