Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

The correct answer is choice B.

Choice A rationale:

A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.

Choice B rationale:

A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.

Choice C rationale:

A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.

Choice D rationale:

A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.

The correct answer is Choice A: Give positive feedback when the client is assertive with staff or clients.

Choice A rationale: Clients with dependent personality disorder exhibit a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. They often struggle with making decisions, expressing their opinions, and engaging in assertive communication. By providing positive feedback when the client exhibits assertive behavior, the nurse reinforces adaptive coping strategies and encourages the development of healthy interpersonal interactions. This approach fosters independence, self-confidence, and autonomy, ultimately promoting a better quality of life for the client.

Choice B rationale: Although setting limits is crucial in managing manipulative behaviors, it is not the primary focus for clients with dependent personality disorder. These clients tend to prioritize pleasing others and avoiding conflict over exploiting or manipulating other individuals. Instead, nurses should emphasize supportive interventions that foster self-reliance and assertiveness.

Choice C rationale: Close monitoring to prevent self-mutilation is not typically associated with the management of dependent personality disorder. This intervention is more relevant for clients with borderline personality disorder or those with a history of self-harm behaviors. Clients with dependent personality disorder may exhibit passive and avoidant behaviors but are less likely to engage in acts of self-mutilation.

Choice D rationale: Discouraging flamboyant or seductive behaviors is an intervention more suited for clients with histrionic personality disorder, not dependent personality disorder. Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behaviors, whereas dependent personality disorder primarily involves a lack of self-confidence and excessive reliance on others for decision-making and emotional support.