A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

Have the client sit by the nurse's desk while awake in a room with the television on

Provide a well-lit room without glare or shadows and limit noise

Keep the room shadowy with soft lighting around the clock, and keep a radio on continuously

Light the room brightly around the clock and awaken hourly to check mental status

Answer and Explanation

The Correct Answer is B

B. This option promotes a calming and supportive environment that minimizes sensory stimuli and helps maintain orientation, reducing the risk of exacerbating symptoms of delirium and illusions.

A. Having the client sit by the nurse's desk may provide some supervision and reassurance, but keeping the television on can contribute to sensory overload and increase confusion, especially if the client is experiencing illusions.

C. Keeping the room shadowy with soft lighting and continuously playing a radio may create an environment that is disorienting and confusing for the client with delirium.

D. Maintaining bright lighting around the clock may disrupt the client's sleep-wake cycle and exacerbate symptoms of delirium. Interrupting the client's sleep by awakening hourly for mental status checks can also contribute to sleep deprivation and increase agitation and confusion

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Correct Answer is C

Explanation

C. Consistent unit routines are essential for clients in the manic phase of bipolar disorder. Maintaining a structured environment with predictable routines can help stabilize mood, reduce agitation, and provide a sense of security for the client.

A. Mania is characterized by heightened activity, impulsivity, and sometimes agitation. Providing a stimulating environment may exacerbate these symptoms and increase the risk of escalating behaviors or agitation.

B. While it may be necessary to provide a safe and quiet space for the client if they become agitated or overwhelmed, scheduling daily seclusion times implies isolation, which can worsen feelings of loneliness or distress.

D. Excessive daytime napping can disrupt the client's sleep-wake cycle and exacerbate symptoms of mania.

A. "You really need to follow the rules of the unit and get out of bed." B. "Let me know when you feel ready to get up." C. "You should rest until you feel able to join the group." D. "I will help you get ready and then you can rest after activities."

Correct Answer is D

Explanation

D. By offering assistance with getting ready and framing participation in activities as a manageable task, the nurse can help the client overcome feelings of inertia and initiate engagement. It acknowledges the client's current difficulties while providing gentle encouragement to participate in the unit's programs.

A. This response may come across as dismissive of the client's feelings and struggles. It may also increase feelings of guilt or inadequacy in the client, potentially worsening their depressive symptoms.

B. It offers support without pressure and allows the client to take the initiative when they feel comfortable to engage in activities. However, it may not provide enough encouragement or assistance for the client to overcome their depressive symptoms and initiate activity.

C. Encouraging prolonged withdrawal from activities without offering support or motivation to engage may contribute to further isolation and exacerbate depressive symptoms.

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A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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