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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Related Questions
Correct Answer is B
Explanation
The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back are consistent with supine hypotension syndrome, also known as vena cava syndrome. This occurs when the weight of the uterus compresses the inferior vena cava, reducing blood flow and causing symptoms.
To address this issue, the nurse should Position the client on their left side. Lying on the left side helps relieve the pressure on the inferior vena cava and improves blood flow. This can alleviate the symptoms and prevent further complications.
Instructing the client to take a brisk walk is not appropriate in this situation, as it may exacerbate the symptoms by increasing heart rate and potentially causing further dizziness or fainting.
Checking the client's temperature is not necessary in relation to these symptoms, as they are not indicative of a fever or infection.
Providing the client with a glass of orange juice may be helpful in some situations, such as if the client is experiencing hypoglycemia. However, in this case, the symptoms are likely due to supine hypotension syndrome, and repositioning the client is the priority intervention.
Correct Answer is D
Explanation
Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.
Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.
Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasms induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.
Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.
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