A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?

A. Hallucinations: As dementia progresses, especially in conditions like Alzheimer's disease, sensory perceptions can become distorted, leading to hallucinations, where the person perceives things that are not present.

B. Paranoia: Paranoia, or irrational suspicions and mistrust, often increases as dementia progresses. The person may become increasingly fearful or suspicious of others, even caregivers or family members.

C. Lethargy: While lethargy can be a symptom of dementia, it is more commonly associated with the earlier stages of the disorder when the person may experience apathy, lack of interest, and reduced energy levels. As the disease progresses, other behavioral changes like agitation or restlessness may become more prominent.

D. Impulsivity: Impulsivity, or acting without forethought or consideration of consequences, can increase as dementia progresses, particularly in certain types of dementia like frontotemporal dementia. This can manifest as impulsive behaviors such as excessive spending, inappropriate social behavior, or risky actions.

E. Disregard for caregiver's feelings: As dementia advances, the person's ability to empathize or recognize the feelings and needs of others may decline. They may become increasingly self-focused or unaware of the impact of their actions on caregivers, leading to behaviors that disregard or overlook the caregiver's feelings and well-being.

A. A client transferred to the medical unit 1 hour ago, after staying 3 days in the ICU for severe blood pressure issues: This client is at the greatest risk for developing delirium due to several factors: recent transfer from the intensive care unit (ICU), history of severe blood pressure issues requiring ICU admission, and the potential for experiencing significant physiological and psychological stressors during the ICU stay. Patients who have been in the ICU are at increased risk for delirium due to factors such as sedative use, mechanical ventilation, and critical illness.

B. A client who has been on the medical unit for a week following a car accident and is waiting for transfer to a rehab facility when a bed becomes available: While this client may have experienced significant trauma from the car accident, they have been stable on the medical unit for a week, which reduces the immediate risk of developing delirium compared to the client recently transferred from the ICU. However, ongoing assessment and monitoring are still necessary.

C. A client who has been NPO for 3 hours, receiving IV fluids, and has not been prescribed any medications: While fasting and receiving IV fluids may contribute to dehydration, which can increase the risk of delirium, this client does not have the same level of acuity or recent history of critical illness as the client transferred from the ICU. Additionally, the absence of prescribed medications reduces the risk of medication-related delirium.

D. A client who is 4 days postoperative following knee surgery and scheduled for discharge home later this morning: This client is in the subacute phase of recovery and is scheduled for discharge home, indicating stability and reduced risk of developing delirium compared to the client recently transferred from the ICU. However, postoperative patients are still at risk for delirium, particularly in the immediate postoperative period, and should be monitored accordingly.