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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
Taping the tube to the child's cheek is not typically done as it can cause discomfort and skin irritation. The tube should be secured with a stabilization device or a specialized dressing designed for gastrostomy tube care.
Applying a skin barrier protectant around the gastrostomy site is a good practice. It helps protect the skin from irritation, breakdown, and leakage of gastric contents, which can cause skin excoriation. This helps maintain the integrity of the skin around the site.
Applying water-soluble lubricant to the site is not necessary for routine site care. Lubrication is typically used when inserting or removing the tube, but it is not part of routine site care.
Correct Answer is B
Explanation
Protein is essential for wound healing as it plays a crucial role in tissue repair and regeneration. It provides the building blocks for new tissue formation and helps in the synthesis of collagen, which is necessary for wound healing. Adequate protein intake promotes wound healing by supporting the growth of new cells, enhancing immune function, and aiding in the formation of new blood vessels.
Calcium is important for bone health but does not directly impact wound healing. However, a balanced diet that includes sources of calcium is generally recommended for overall health. Vitamin D plays a role in bone health and has some influence on immune function and wound healing. However, the primary focus in this scenario should be on protein intake.
Fats, specifically essential fatty acids, are necessary for overall health and immune function. However, increasing fats in the diet may not directly impact wound healing. It is important to consume a balanced diet that includes healthy fats, but the emphasis for wound healing is on protein intake.
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