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. Victims of abuse, especially perpetrated by family members, may feel conflicted about reporting the abuse due to feelings of guilt, shame, or fear of repercussions.
A. This implies that the client may believe they cannot report the abuse because they perceive abuse as only valid if there is physical evidence of harm. However, it's important to recognize that abuse can take various forms, including emotional, psychological, financial, and neglectful abuse, which may not always leave physical evidence.
B. While it's true that cases of abuse perpetrated by family members can be complex and challenging to address legally, there are laws and resources available to protect victims of family abuse. Many jurisdictions have laws specifically addressing domestic violence and elder abuse.
C. Reporting abuse to appropriate authorities, such as adult protective services or law enforcement, does not necessarily require hiring legal representation.
Correct Answer is D
Explanation
D. It acknowledges the client’s comfort while emphasizing the nurse’s professional role. It sets clear boundaries and reinforces that the nurse’s primary purpose is to provide care and support within the therapeutic context.
A. This response acknowledges the client’s feelings but does not set clear boundaries. It may
inadvertently encourage the client to view the nurse as a friend rather than a professional caregiver.
B. While this response establishes boundaries, it may come across as abrupt or cold. It lacks empathy and understanding.
C. This response reflects empathy and encourages further exploration of the client’s feelings. However, it does not address the professional boundaries explicitly.
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