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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The occiput refers to the back of the head. Placing a small pillow or padding under the occiput can help relieve pressure and provide support to the client's head and neck when they are placed in the supine position.
Breasts: When in the prone position, breasts may be compressed or flattened. To relieve pressure, it may be necessary to use positioning techniques that distribute weight evenly and avoid direct pressure on the breasts, such as using cushions or foam pads to support the chest and torso.
Heels: The heels are prone to pressure ulcers when a client is lying in the supine position for extended periods. To relieve pressure, it is important to use proper heel offloading techniques, such as placing heel protectors or pillows under the lower legs to elevate the heels off the bed surface and prevent direct pressure.
Coccyx: The coccyx is the tailbone region at the base of the spine. When in the supine position, pressure on the coccyx can be relieved by using a cushion or padding under the pelvic area, specifically under the bony prominence of the coccyx, to reduce direct pressure and provide comfort.
Correct Answer is A
Explanation
The correct answer is choicea. Obtain the client’s blood pressure in the other arm.
Choice A rationale:
Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.
Choice B rationale:
Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.
Choice C rationale:
Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.
Choice D rationale:
Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.
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