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 ["A","C"]
Explanation
A. Assign the client to a negative-pressure airflow room:Varicella zoster (chickenpox) is highly contagious and can be transmitted through airborne droplets.A negative-pressure airflow room helps prevent the spread of the virus to other patients and healthcare workers.
B.Have visitors remain at least 0.91 m (3 feet) away from the client: While maintaining distance is generally advisable, it is not the primary intervention for varicella. The focus should be on preventing transmission through other means.
C.Initiate contact precautions for the client:Correct!Contact precautions are essential for varicella-zoster patients. This includes using gloves and gowns when in direct contact with the client or their environment. Airborne precautions are also recommended because varicella is highly contagious.
D.Administer aspirin if the client develops a fever: Aspirin is generally avoided in children with varicella due to the risk of Reye’s syndrome. Acetaminophen (paracetamol) is a safer choice for fever management.
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
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