A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium. B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention. C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked. D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.