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 A
Explanation
This statement accurately reflects the client's own account of what happened, providing important information about the circumstances leading to the fall. Including the client's statement helps document the client's perspective and can contribute to a more comprehensive understanding of the event.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame to the assistive personnel without sufficient evidence. It is important to maintain objectivity and avoid making assumptions or assigning fault without proper investigation or documentation of facts.
C. "The client does not appear to have any injuries resulting from the fall." While it is important to assess the client for any injuries after a fall, documenting this information may be more appropriate in the client's assessment or nursing notes rather than in the specific documentation about the fall incident itself.
D. "An incident report has been completed and sent to risk management." While it is important to report falls and complete an incident report for quality improvement and risk management purposes, this information is more relevant to internal documentation and reporting processes rather than inclusion in the medical record for the client's care.
Correct Answer is A
Explanation
ADHD (Attention-Deficit/Hyperactivity Disorder) is characterized by symptoms such as difficulty sustaining attention, impulsivity, and hyperactivity. Methylphenidate is a commonly prescribed medication for ADHD that helps improve focus, attention, and impulse control.
The ability to complete homework on time suggests improved focus and attention, which are positive effects of methylphenidate in managing ADHD symptoms. It indicates that the medication is helping the child stay on task and concentrate better, leading to improved academic performance.
"Our child has lost some weight since his last appointment" suggests a potential side effect of methylphenidate, which can cause appetite suppression and weight loss.
"Our child has increased his daily caloric intake" might be a response to the weight loss side effect, but it does not directly indicate the effectiveness of the medication.
"Our child has a better grasp of reality" is a subjective statement that does not specifically relate to ADHD symptoms or the expected effects of methylphenidate.
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