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 D

Explanation

Correct answer: D

veracity, in (option A) is incorrect because it refers to telling the truth and being honest with the client. While the nurse's action in obtaining a healthy meal for the client is a positive action, it is not directly related to veracity.

countertransference in (option B) is incorrect because it, refers to the nurse's emotional or personal reaction towards the client that may influence their behaviour or response. It is not applicable to the scenario described.

C. Boundary Crossing happens when a professional line is blurred. In this case, the nurse prioritizes the client's well-being, not a personal connection.

D. Promoting trust involves actions that build rapport, establish a therapeutic relationship, and demonstrate caring and empathy towards the client. By interrupting the bath to obtain a healthy meal for the client, the nurse shows responsiveness to the client's needs, which can enhance trust and confidence in the nurse's care

A. “I can have a meal up to 2 hours before the procedure." B. "I will feel a warming sensation after the injection of the dye." C. "I do not need to sign a consent form before this procedure." D. "I should limit my fluid intake for 2 days after the procedure."

Correct Answer is B

Explanation

During an intravenous pyelogram (IVP), a contrast dye is injected into the client's veins, and X-ray images are taken to visualize the urinary tract. The dye used in an IVP can cause a warming or flushing sensation as it circulates through the body. The client's statement indicates an understanding of this common sensation associated with the procedure.
A. "I can have a meal up to 2 hours before the procedure": This statement is incorrect. Typically, for an IVP, the client is required to have an empty stomach before the procedure to ensure accurate imaging results. The client should follow the specific instructions provided by their healthcare provider regarding fasting before the procedure.
C. "I do not need to sign a consent form before this procedure": This statement is incorrect. Informed consent is required for most medical procedures, including an IVP. The client should sign a consent form after receiving all the necessary information about the procedure, its risks, and benefits.
D. "I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. After an IVP, it is generally advised to increase fluid intake to help flush out the contrast dye from the body and prevent potential complications. The client should follow the specific instructions provided by their healthcare provider regarding post-procedure fluid intake.

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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 begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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