According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?
Identify the underlying cause
Tell the client that hallucinations are not real
Speak slowly and clearly
Request the assistance of physical therapy
The Correct Answer is A
Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.
Identifying and treating the cause can help resolve the delirium and prevent further complications.
Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.
Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.
Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Complete a vascular assessment: Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.
B. Assess the cranial nerves: This is the correct action to initiate next. Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
C. Decrease environmental stimuli: While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.
D. Administer an antipyretic: Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.
Correct Answer is A
No explanation
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