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 ["A","B","D","E"]

Explanation

A. Providing frequent meals and snacks is generally beneficial, it’s essential to focus on nutritious options.

C. Manic episodes can lead to impulsive behavior, increased activity, and risk-taking. Close monitoring ensures early detection of any safety concerns, such as self-harm or aggression.
D. Manic clients are often hypersensitive to stimuli, and a calm, low-stimulation environment can help reduce agitation and prevent exacerbation of symptoms.
E. While adequate rest is essential, discouraging daytime naps may help regulate the client’s sleep patterns and prevent excessive energy levels associated with mania.

B. Regular weight monitoring is essential for assessing overall health, but it may not be a priority specifically related to mania.

A. Provide a stimulating environment. B. Schedule daily seclusion times. C. Have consistent unit routines. D. Discourage daytime napping.

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.

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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 creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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

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