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 A
Explanation
A. Correct. This situation involves a potential medication error due to the electronic IV pump delivering excessive fluid, which requires documentation and an incident report for reporting and tracking purposes.
B. While observing another nurse's practice is important, the scenario does not involve an incident that requires reporting via an incident report.
C. This situation may warrant a medication incident report, but the family member's administration of PCA might be within their scope if properly trained and authorized.
D. This scenario involves a side effect of a medication, but it is not a situation requiring an incident report unless it is a severe or unexpected reaction.
Correct Answer is C
Explanation
Restlessness can be a common manifestation of pain. When a client is experiencing unrelieved pain, they may exhibit restlessness, which can include fidgeting, pacing, or frequent position changes in an attempt to find relief. Restlessness may also be accompanied by increased heart rate, elevated blood pressure, and changes in respiratory rate.
Difficulty swallowing (dysphagia) is not a specific indicator of unrelieved pain in a client with a spinal epidural for a herniated disc. Difficulty swallowing can be caused by various factors, including anatomical abnormalities, neurological conditions, or muscle dysfunction.
Constipation is not a specific indicator of unrelieved pain in this scenario. Constipation can be a side effect of certain medications, including opioids that are commonly used to manage pain.
However, it is not an exclusive indicator of unrelieved pain and can be managed through interventions such as adequate hydration, fiber intake, and appropriate bowel regimen.
Urinary retention is not a specific indicator of unrelieved pain in this context. It can be associated with several factors, including the use of certain medications, urinary tract infections, or neurological conditions. Urinary retention may require assessment and management but does not necessarily indicate unrelieved pain.
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