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

A. A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min likely requires closer monitoring and assessment of respiratory status. This may be more suitable for a registered nurse (RN), especially considering the potential for respiratory complications postoperatively. nd dietary considerations.

B.A client with a urinary output of 30 mL in the past hour may require assessment and intervention related to urinary function. While this may not necessarily require the expertise of an RN, it may be within the scope of practice for an LPN to monitor urinary output and report findings to the RN.

Option C, a newly admitted client requiring an admission assessment, should also be assigned to an RN, as this involves a comprehensive assessment that may require identifying potential risks and initiating appropriate interventions.

D. A client with a new diagnosis of diabetes mellitus awaiting teaching about meal planning may benefit from education provided by an RN or a certified diabetes educator (CDE) due to the complexity of diabetes management and the need for individualized teaching.

A. I can remove my security band to give it to a family member. B. I will have an identification band that matches the one my baby wears. C. I can take my baby to the lobby to visit family. D. I will carry my baby to the nursery.

Correct Answer is B

Explanation

I can remove my security band to give it to a family member.

In healthcare facilities, security measures are implemented to ensure the safety and identification of patients and newborns. One common security measure is the use of identification bands for both the mother and the baby. These bands typically have matching identification numbers or barcodes that help staff members verify the identity of the individuals and ensure they are correctly paired.

Option A is incorrect because removing the security band and giving it to a family member would compromise the system's security and potentially lead to confusion or incorrect identification.

Option C is incorrect because taking the baby to the lobby to visit family can increase the risk of unauthorized individuals gaining access to the baby or potentially interfering with the security measures in place.

Option D is incorrect because carrying the baby to the nursery without following the facility's security protocols can also compromise the identification and safety measures.

The best response indicating an understanding of the teaching is option B, as it recognizes the importance of having an identification band that matches the one worn by the baby. This indicates awareness of the security measures in place and the need to ensure accurate identification and safety.

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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 charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

Correct Answer is B

Explanation

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