A nurse is caring for a patient who wants to know how albuterol aids his breathing. What should the nurse’s response be? (Select all that apply)

Choice A rationale

Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.

Choice B rationale

Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.

Choice C rationale

While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.

Choice D rationale

Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.

Choice A rationale

Establishing a patient relationship is important, but it’s not the first action the nurse should take. The nurse must first ensure safety for all involved.

Choice B rationale

Exploring the truth of the patient’s statements is a part of the therapeutic process, but it’s not the first step. The immediate concern should be to ensure safety.

Choice C rationale

Setting behavioral limits for the patient is the first action the nurse should take. This is crucial in managing a patient who has shown aggressive behavior. It helps to establish boundaries and expectations, which can prevent further aggressive incidents.

Choice D rationale

While it’s important to explain to the patient that the behavior was unacceptable, this is not the first action. The immediate priority is to ensure safety by setting behavioral limits.