A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical...

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to “catch these baby angels flying around my head.” While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply.

1. Decreasing as much “foreign” stimuli as possible.

2. Avoiding challenging the client's perceptions about “baby angels.”

3. Orienting the client about his medical condition.

4. Gently presenting reality as needed.

5. Calling the client's family to report his onset of dementia.