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 A

Explanation

A. Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as "Would you like tea or juice?" instead of an open-ended question, helps reduce confusion and frustration.

B. Using written signs to assist with locating the bathroom is incorrect. While cues can be helpful, clients with Alzheimer's disease often experience difficulty processing written information as the disease progresses. Using pictures or symbols instead of words is more effective.

C. Providing a stimulating environment for the client is incorrect. An overly stimulating environment can increase agitation and confusion. A calm, structured setting with minimal distractions is better for clients with Alzheimer's disease.

D. Using confrontation to manage the client’s behavior is incorrect. Confronting or arguing with a client who has Alzheimer's disease can lead to increased agitation and distress. Instead, caregivers should use redirection and reassurance to manage behaviors effectively.

A. Tonic-clonic seizures B. Paresthesias C. Disorientation D. Sleep apnea

Correct Answer is C

Explanation

A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.

B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.

C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.

D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.

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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

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