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 D

Explanation

A. Copy of the client's advance directives: While advance directives are important documents, they are typically filed with the medical record, not specifically included in postmortem documentation. The focus for postmortem documentation is on the body and relevant events surrounding the death.

B. Cause of the client's death.: The cause of death is typically recorded in the official death certificate, which is not part of postmortem nursing documentation. The nurse should not make a diagnosis about the cause of death but may note any relevant findings.

C. Last set of the client's vital signs: Vital signs taken at the time of death may be noted as part of the clinical documentation, but they are not specifically part of postmortem documentation. The postmortem documentation should focus on observations regarding the body and its condition.

D. Location of the identification tag on the client’s body: The nurse should document the location of identification tags on the body to ensure proper identification and to prevent confusion or errors in postmortem care. This is an important detail in postmortem documentation.

A. Decreased body temperature B. Increased incisional drainage C. Hypertension D. Bradycardia

Correct Answer is C

Explanation

A. Decreased body temperature is incorrect. A thyroid storm is characterized by a hypermetabolic state, so a decreased body temperature would be inconsistent with the condition. In fact, patients with thyroid storm typically have increased body temperature (fever).

B. Increased incisional drainage is incorrect. While increased drainage could indicate a wound infection or other surgical complications, it is not a primary indicator of thyroid storm, which involves a hyperactive thyroid response.

C. Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.

D. Bradycardia is incorrect. Bradycardia would be expected in conditions like hypothyroidism, not thyroid storm. Thyroid storm typically presents with tachycardia, which is a hallmark sign.

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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 postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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