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 B

Explanation

B. PPD requires timely intervention, and antidepressant medications can be effective in managing symptoms. Anticipating a prescription allows the nurse to prepare for the next steps in the client’s care.

A. While assessing for suicidal or harmful thoughts is essential, it is not the priority in this situation. The client’s symptoms (feeling “down,” sadness, lack of energy, and wanting to cry) are indicative of postpartum depression (PPD), and addressing her emotional well-being is the immediate concern.

C. While coping skills are important, focusing on the family’s coping mechanisms is not the priority at this moment. The client’s individual needs related to PPD take precedence.

D. Although postpartum and newborn care education is essential, it is not the priority when the client is experiencing symptoms of depression. Addressing the client’s emotional state and ensuring appropriate treatment are more urgent.

A. Monitor food intake and eliminate potential sources of tyramine. B. Assess for weight loss and difficulty sleeping. C. Monitor the client for migraines. D. Implement suicide precautions.

Correct Answer is D

Explanation

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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