A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Rationale:

A. "You should appoint a family member as your health care surrogate.": While clients may choose a family member, they are not required to do so. The decision is personal, and clients can appoint anyone they trust, regardless of relation, to serve as their health care surrogate.

B. "Once you have completed a living will, it cannot be changed.": A living will can be revised or revoked at any time by the client as long as they remain mentally competent. Clients retain the right to alter their advance directives based on changes in preferences or health status.

C. "You will need an attorney to appoint a health care surrogate.": Appointing a health care surrogate does not require an attorney. Most states allow individuals to complete this process using standardized forms and witnesses, without the need for legal representation.

D. "Your health care surrogate will make decisions on your behalf if you are unable.": A health care surrogate is authorized to make medical decisions when the client is no longer capable of doing so. This ensures that the client’s preferences are respected even if they become incapacitated.

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.