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?

Remind the client of the day and time often.

Offer the client several choices at mealtimes.

Avoid discussing the client's fears.

Alternate daily caregivers.

Answer and Explanation

The Correct Answer is A

A. Correct.

Option A, reminding the client of the day and time often, aligns with this goal. Orienting the individual to time and place can help reduce confusion and disorientation commonly associated with delirium.
B. Incorrect. Offering the client several choices at mealtimes, might not directly address the issue of orientation and may potentially overwhelm the individual, exacerbating their confusion.

C. Incorrect. Discussing the client's fears and addressing their concerns is important for providing appropriate care and support.
D. Incorrect. Alternating daily caregivers may increase confusion for the client experiencing delirium. Consistency in care providers can be beneficial.

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Correct Answer is B

Explanation

A. Incorrect. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.

A. Check on the client every 10 min during the bath. B. Add bath oil to the water after the client gets into the tub. C. Drain the tub water before the client gets out. D. Allow the client to remain in the bath for 30 min.

Correct Answer is C

Explanation

Answer is:Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

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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 at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is B

Explanation

A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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