A nurse is contributing to the plan of care for a client who has delirium and is experiencing hallucinations. Which of the following interventions should the nurse recommend to include?
Place the client in restraints.
Offer the client a variety of activities to choose from.
Communicate with the client using simple, direct statements.
Limit how often the client's partner can visit.
The Correct Answer is C
A. Place the client in restraints: Physical restraints are used only as a last resort when the client poses an immediate danger to self or others. In delirium, restraints can worsen agitation, increase confusion, and elevate the risk of injury or further cognitive decline. Nonpharmacologic de-escalation and environmental modifications are preferred initial interventions.
B. Offer the client a variety of activities to choose from: Clients with delirium have impaired attention, fluctuating levels of consciousness, and reduced ability to process multiple stimuli. Providing numerous choices can increase confusion and cognitive overload. Care should focus on structured, simple activities rather than offering multiple options.
C. Communicate with the client using simple, direct statements: Delirium impairs cognition, attention, and comprehension, making complex communication difficult. Using short, clear, and direct statements helps reduce misinterpretation and supports orientation. Consistent, simple communication decreases anxiety and promotes better understanding in hallucinations.
D. Limit how often the client's partner can visit: Familiar individuals can provide reassurance, assist with reorientation, and decrease anxiety in clients with delirium. Restricting visits may increase confusion and agitation. Encouraging the presence of trusted family members often supports cognitive stabilization and emotional comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Choose the most restrictive type of restraint that will fit the client: Restraint use follows the principle of least restriction. The least restrictive device that ensures safety should always be selected to preserve client autonomy and reduce complications such as agitation, decreased circulation, or psychological distress. Choosing the most restrictive option increases the risk of harm and violates best practice guidelines.
B. Assess skin integrity under the restraint once per day: Clients in restraints require frequent monitoring, including assessment of skin integrity, circulation, and neurovascular status at least every 2 hours or according to facility policy. Assessing only once per day is insufficient and increases the risk of pressure injuries, impaired circulation, and nerve damage.
C. Attach the restraint securely to the side rail when the client is in bed: Restraints should be secured to the bed frame, not the side rails. Side rails move when raised or lowered, which can cause injury or accidental tightening of the restraint. Securing to the immovable bed frame ensures consistent positioning and reduces injury risk.
D. Secure the restraint with an easy-to-release tie: Restraints should be secured using a quick-release knot or buckle that allows rapid removal in case of emergency. This method ensures client safety by permitting immediate release during situations such as respiratory distress or fire, while still maintaining appropriate security during use.
Correct Answer is B
Explanation
A. "You can resume a regular diet 3 days after your procedure.": Most adolescents can resume their regular diet shortly after a cardiac catheterization once vital signs are stable and there are no complications. Delaying diet for 3 days is unnecessary unless the provider specifies restrictions due to other medical conditions.
B. "You can take a shower 1 day after your procedure.": Showering is generally allowed 24 hours after cardiac catheterization, provided the dressing over the insertion site remains dry and intact. This instruction promotes hygiene while minimizing the risk of infection at the puncture site.
C. "You can begin exercising 2 days after your procedure.": Physical activity is typically restricted for several days to a week after catheterization to allow the vascular access site to heal and reduce the risk of bleeding or hematoma formation. Exercising too soon could compromise site integrity.
D. "You can return to school 1 week after your procedure.": Returning to school may depend on the adolescent’s overall recovery and provider instructions. While many can resume school within a few days, the primary focus immediately after the procedure is ensuring safe hygiene and access site healing rather than full activity, making showering the first priority instruction.
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