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 C

Explanation

A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.

A. "You can safely take this medication if you become pregnant." B. "You can skip a dose of this medication if you are nauseated." C. "You should expect to have blood work every 6 months while taking this medication." D. "You might experience swollen gums while taking this medication."

Correct Answer is D

Explanation

A. Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B. Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C. Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D. Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.

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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?

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Naxlex Comprehensive Predictor Exams

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