A nurse is caring for a client who was admitted with delirium five days ago. The client seeks permission from the nurse before performing ADLs. Which of the following actions should the nurse take?
Quiz the client with orientation questions.
Allow the client to function independently.
Prepare the client for discharge.
Determine the client's level of awareness.
The Correct Answer is D
A: Quizzing the client might be part of an assessment but not the initial action.
B: Allowing independent function is important, but assessing cognitive function to tailor support is essential first.
C: Preparing for discharge might be premature without assessing readiness and stability.
D: Assessing awareness and cognitive function helps guide appropriate support and independence levels.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: This is coercive and inappropriate, potentially causing distress.
B: This does not address the client’s expressed feelings of fatigue and could feel dismissive.
C: This supportive approach helps the client engage in activity at her own pace, promoting participation without coercion.
D: This encourages avoidance, which may further reinforce depressive behaviors and social withdrawal.
Correct Answer is A
Explanation
A: Sundown syndrome involves increased confusion and agitation during the late afternoon or evening in individuals with dementia.
B: Dementia is a broader condition that sundown syndrome falls under but does not specifically describe the evening confusion.
C: Age-associated memory impairment refers to normal changes in memory due to aging and does not include confusion and agitation.
D: Delirium is typically acute and can be caused by various factors, not specifically tied to time of day like sundown syndrome.
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