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.
A. 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.
B. 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.
D. Alternating daily caregivers can disrupt the 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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.
One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.
Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.
The client reported that muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation.
Correct Answer is D
Explanation
range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.
Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.
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