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?

Alternate daily caregivers.

Remind the client of the day and time often.

Offer the client several choices at mealtimes.

Avoid discussing the client's fears.

Answer and Explanation

The Correct Answer is B

A. Alternate daily caregivers is incorrect. Consistent caregiving is important for clients experiencing delirium to provide stability and reduce confusion. Frequent changes in caregivers can increase anxiety and disorientation.

B. Remind the client of the day and time often is correct. Frequent reminders of the day, time, and orientation help ground the client in reality and reduce confusion. This is an essential part of managing delirium by addressing disorientation and improving cognitive clarity.

C. Offer the client several choices at mealtimes is incorrect. Giving too many choices can lead to overwhelm and confusion in clients with delirium. It is better to offer simple, limited options to avoid stress or difficulty in decision-making.

D. Avoid discussing the client's fears is incorrect. Addressing a client's fears is important in the management of delirium. It is more beneficial to acknowledge and provide reassurance, which can help reduce anxiety and the psychological stress that might exacerbate delirium.

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Correct Answer is C

Explanation

A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.

B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.

C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.

D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.

A. Apply rubber-soled slippers before ambulation. B. Determine the client's ability to use the call light. C. Create a schedule with an assistive personnel to do hourly rounding for the client. D. Move the bedside table with the client's personal items close to the bed.

Correct Answer is B

Explanation

A. "Apply rubber-soled slippers before ambulation.": This is important for safety, but it is not the first step in fall prevention. The client needs to be able to call for assistance if needed before moving around.

B. "Determine the client's ability to use the call light.": This should be the first step. Ensuring that the client can easily use the call light in case they need help is a foundational fall prevention strategy. It is essential for maintaining the client’s safety and enabling them to request assistance when needed.

C. "Create a schedule with an assistive personnel to do hourly rounding for the client.": Hourly rounding is an important fall prevention measure, but it should follow initial steps such as ensuring the client can call for help. It can be implemented after determining how the client will communicate needs.

D. "Move the bedside table with the client's personal items close to the bed.": This is a helpful precaution, as it reduces the need for the client to reach or stand to access their belongings. However, the most critical initial step is ensuring the client can safely summon help if needed.

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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

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Correct Answer is C

Explanation

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