What is the first step the nurse should take when Ms. Horton experiences anxiety due to external noise?

To manage Ms. Horton's anxiety effectively, it is crucial for the nurse to first assess her orientation status. This step is fundamental because understanding a patient's awareness of their environment, time, and self is critical in determining the underlying causes of anxiety. If a patient appears disoriented, their anxiety could stem from confusion or a lack of understanding of the situation they are in, which could be exacerbated by external noise.

By assessing Ms. Horton's orientation, the nurse can gauge whether her anxiety is a reaction to the noise or if it is related to an underlying condition, such as delirium or acute confusion. This assessment will inform the nurse of the appropriate interventions to take next, whether that involves providing reassurance, employing therapeutic communication techniques, or considering other interventions based on her mental status.

This approach helps ensure that the nurse responds appropriately and effectively addresses the patient's needs, rather than potentially escalating the situation by rushing to other interventions without fully understanding the patient's condition.