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.

Answer and Explanation

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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Correct Answer is B

Explanation

Turn the child on to their side

When a child is experiencing a tonic-clonic seizure, the priority is to ensure their safety and protect their airway. Turning the child onto their side helps to prevent aspiration and maintain an open airway by allowing any saliva or fluids to drain out of the mouth. This position also helps to minimize the risk of injury.

The other options are incorrect:

Restraining the child's upper extremities in (option A) is not recommended during a seizure as it can potentially cause harm to the child or others around them.

Placing a padded tongue blade in the child's mouth in (option C) is an outdated practice that is no longer recommended. It can cause injury and is not necessary during a seizure.

Placing a pillow under the child's head in (option D) is generally not recommended during a seizure. It can interfere with the positioning of the head and may compromise the airway. The focus should be on maintaining an open airway and preventing injury, which is achieved by turning the child onto their side.

A. The client has artificial flowers in the room. B. The client is assigned to a room with negative airflow. C. The client's meal tray contains hard-boiled eggs D. The client's meal tray includes ice cream with fresh fruit.

Correct Answer is D

Explanation

A. Artificial flowers in the room: While artificial flowers can harbor dust and allergens, they are not a significant risk factor for infection in a neutropenic client with HIV. The primary concern is bacterial or fungal exposure, which is unlikely to be significantly affected by artificial flowers.Still, due to the need for a highly sterile environment for neutropenic patients, artificial flowers are typically avoided in clinical settings.

B. Room with negative airflow: A room with negative airflow is designed to prevent airborne pathogens from spreading outside the room. However, this measure is more relevant for clients with contagious respiratory infections (e.g., tuberculosis).

C. Meal tray with hard-boiled eggs: Hard-boiled eggs are generally safe for most clients. However, in a neutropenic client, the risk lies more in raw or undercooked eggs due to potential bacterial contamination (e.g., Salmonella). Hard-boiled eggs are fully cooked and less likely to pose a significant risk.

D. Meal tray with ice cream and fresh fruit: This choice presents a higher risk. Neutropenic clients should avoid fresh fruits (especially unwashed) due to potential bacterial and fungal contamination. Ice cream, although pasteurized, can also harbor bacteria if not handled properly.

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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 enters the room of a school-age child and finds them on the floor experiencing a tonic-colonic seizure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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