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
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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Related Questions
Correct Answer is D
Explanation
D. Remaining with the client provides support and reassurance during a period of agitation and restlessness. The presence of the nurse can help the client feel safe and supported, and it allows the nurse to assess the client's condition closely and intervene as needed.
A. While administering a PRN (as needed) sleeping medication may be considered in some situations, it is not the first-line intervention when a client is experiencing agitation and restlessness.
B. Encouraging the client to return to bed may be appropriate if they are willing and able to do so. However, if the client is agitated and pacing the floor, they may not feel comfortable or able to go back to bed.
C. Exploring alternatives to pacing the floor involves assessing the client's needs and preferences and identifying activities or strategies that may help alleviate agitation and promote relaxation. However, proper observation of the client behavior should be prioritized.
Correct Answer is D
Explanation
D. Barbiturates can cause respiratory depression, hypoventilation, and potentially respiratory arrest, which can lead to hypoxia and cardiac arrest if not promptly recognized and managed.
A. While it's important to assess for any additional drugs or substances that the client may have ingested, this action is not the priority when managing a client with a barbiturate overdose.
B. Seizures can occur as a result of barbiturate overdose, but respiratory depression is the more immediate and life-threatening concern.
C. Ipecac is no longer recommended for the induction of vomiting in cases of drug overdose due to the risk of complications such as aspiration pneumonia and delayed treatment.
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