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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.
C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.
D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
Correct Answer is A
Explanation
Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.
Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.
Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today