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 C
Explanation
Ciprofloxacin is a fluoroquinolone antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. It is important for the client to be aware of this potential side effect and take appropriate precautions, such as using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure while taking the medication.
"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or mineral supplements containing calcium, magnesium, aluminum, or iron, as they can interfere with the absorption of the medication. If the client experiences gastrointestinal upset, they should consult their healthcare provider for appropriate management.
"Restrict your daily fluid intake while taking this medication." It is important for the client to maintain adequate hydration while taking ciprofloxacin, as it is important for the elimination of the medication from the body. Restricting fluid intake can lead to dehydration and may affect the effectiveness of the medication. The client should be encouraged to drink plenty of fluids unless otherwise instructed by their healthcare provider.
"Expect to experience diarrhea while taking this medication." While gastrointestinal side effects such as diarrhea can occur with ciprofloxacin, it is not appropriate to state that the client should expect to experience it. Diarrhea can be a sign of a serious adverse reaction, such as Clostridium difficile infection, and should be reported to the healthcare provider for further evaluation and management.
Correct Answer is B
Explanation
A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.
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