A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

A. "Who is lying about you and trying to poison you?": This response may come across as confrontational and may not effectively address the client's underlying fear or paranoia. It could potentially escalate the client's anxiety or reinforce their delusions by implying that the nurse believes the accusations are valid.

B. "You seem to be having very frightening thoughts.": This response acknowledges the client's experience without directly challenging or validating the content of their delusions. It conveys empathy and concern while also opening the door for further exploration of the client's feelings and experiences. By acknowledging the frightening nature of the client's thoughts, the nurse demonstrates understanding and provides an opportunity for therapeutic dialogue.

C. "You are mistaken. Nobody is lying about you or trying to poison you.": This response denies the client's reality and contradicts their experience, which can be invalidating and may cause the client to feel misunderstood or dismissed. It's important to avoid outright denial of the client's beliefs, as it can damage the therapeutic relationship and hinder effective communication.

D. "Why do you think you are being lied about and poisoned?": While this response seeks to explore the client's thoughts and feelings, it may be perceived as challenging or confrontational. It could unintentionally reinforce the client's delusions by inviting them to elaborate on their paranoid beliefs without first acknowledging the distress they are experiencing.

A. Assist the client to the correct room: This option addresses the immediate safety concern by guiding the client back to their own room, reducing distress for both the client and the other resident. It promotes dignity and minimizes the risk of agitation or further disruptive behavior.

B. Place the client in restraints: Restraints should only be used as a last resort for safety when all other measures have been exhausted and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful to individuals with Alzheimer's disease and should not be used unless absolutely necessary.

C. Reorient the client to time and place: Reorientation may not be effective for clients with advanced Alzheimer's disease, as their cognitive impairments may limit their ability to understand or retain this information. Additionally, reorientation may not address the immediate safety concern posed by the client's behavior.

D. Move the client to a room at the end of the hall: While this option may be considered in some situations to minimize disruption to other residents, it does not address the underlying issue of the client's confusion or wandering behavior. Additionally, moving the client may cause further distress and confusion.