A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Choice A reason: Sedative medications may be used to manage agitation, but they carry risks such as respiratory depression and worsening confusion. They are not the first-line intervention for preventing injury in delirium. Choice B reason: One-on-one observation is the safest and most immediate intervention to prevent injury in a client with delirium. It allows for continuous monitoring and rapid response to behavioral changes without compromising the client’s dignity or safety. Choice C reason: Antipsychotic medications may be prescribed for severe agitation or psychosis, but they are not the first step in managing delirium-related safety concerns. Choice D reason: Restraints should be used only as a last resort due to the risk of physical and psychological harm. They do not address the underlying cause of delirium and may exacerbate agitation.