A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Avoid discussing the client's fears.

Offer the client several choices at mealtimes.

Remind the client of the day and time often.

Alternate daily caregivers.

Answer and Explanation

The Correct Answer is C

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

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Correct Answer is A

Explanation

This statement accurately reflects the client's own account of what happened, providing important information about the circumstances leading to the fall. Including the client's statement helps document the client's perspective and can contribute to a more comprehensive understanding of the event.

"The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame to the assistive personnel without sufficient evidence. It is important to maintain objectivity and avoid making assumptions or assigning fault without proper investigation or documentation of facts.

"The client does not appear to have any injuries resulting from the fall." While it is important to assess the client for any injuries after a fall, documenting this information may be more appropriate in the client's assessment or nursing notes rather than in the specific documentation about the fall incident itself.

"An incident report has been completed and sent to risk management." While it is important to report falls and complete an incident report for quality improvement and risk management purposes, this information is more relevant to internal documentation and reporting processes rather than inclusion in the medical record for the client's care.

A. Calcium supplement B. Docusate C. Cimetidine D. Naproxen

Correct Answer is D

Explanation

The nurse should identify Naproxen as an over-the-counter product that is unsafe for use with enoxaparin. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when used in combination with anticoagulant medications like enoxaparin. Both enoxaparin and Naproxen have anticoagulant effects, and using them together can significantly increase the risk of bleeding complications.

On the other hand, calcium supplements, docusate (a stool softener), and cimetidine (an H2 blocker) do not have direct interactions or pose significant risks when used with enoxaparin. However, it is always important for the client to inform their healthcare provider about all medications, including over-the-counter products, they are taking to ensure there are no potential interactions or contraindications specific to their individual situation.

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A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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