The nurse is continuing to assist in the care of the client.
Which of the following actions should the nurse take? Select all that apply.
Provide the client with information about what to expect during their care. Reorient the client often.
Ask the client's partner to stay with the client as much as possible.
Maintain a well-lit environment.
Request that the client have the same caregivers with every shift.
Request that the client's family bring the client's eyeglasses from home.
Acknowledge the client's feelings.
Write the full date on the client's whiteboard.
Correct Answer : A,B,C,D,E,F,G
A. Provide the client with information about what to expect during their care. Reorient the client often: Frequent reorientation and explaining procedures help reduce confusion and anxiety, which are common in older adults experiencing delirium, especially postoperatively.
B. Ask the client's partner to stay with the client as much as possible: Familiar presence provides comfort, reassurance, and a sense of safety, which can help reduce agitation and disorientation in clients with delirium.
C. Maintain a well-lit environment: Proper lighting reduces visual misperceptions and illusions that may contribute to the client’s hallucinations or confusion. Maintaining adequate lighting is a nonpharmacologic intervention for delirium.
D. Request that the client have the same caregivers with every shift: Continuity of care minimizes the number of new faces the client must process, which helps reduce confusion and builds a sense of safety.
E. Request that the client's family bring the client's eyeglasses from home: Corrective lenses help reduce sensory deprivation, which can worsen confusion and delirium. Having the client’s glasses improves orientation and ability to recognize their surroundings.
F. Acknowledge the client's feelings: Validating the client’s emotions, such as fear from hallucinations, supports therapeutic communication, reduces agitation, and promotes trust between the client and caregiver.
G. Write the full date on the client's whiteboard: Displaying the date and other orientation cues helps the client remain aware of time, reducing confusion and supporting reorientation during delirium episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F","G","H"]
Explanation
Rationale for correct choices:
• Heart rhythm irregular: Bradycardia and arrhythmias are common in adolescents with severe caloric restriction and low body weight. Reporting this finding is essential because cardiac complications are a leading cause of morbidity in anorexia nervosa.
• Blood pressure 80/50 mm Hg: Hypotension indicates cardiovascular compromise from malnutrition and fluid/electrolyte imbalance. Immediate provider awareness is needed to prevent syncope, shock, or other complications.
• Hypoactive bowel sounds: Reduced gastrointestinal motility is associated with prolonged starvation and electrolyte imbalances. Reporting this finding helps guide interventions for nutrition and gastrointestinal support.
• Weight 39.9 kg (88 lb): Significant weight loss over a short period and extremely low body weight indicates severe malnutrition. This is critical information for the provider for determining hospitalization or intensive intervention.
• BMI 16.1 (4th percentile): A BMI this low confirms severe underweight status and risk for multisystem complications. Reporting ensures the provider can prioritize medical and nutritional stabilization.
• Adolescent exercising excessively: Excessive exercise and caloric restriction are behaviors consistent with anorexia nervosa and increase risk for cardiac events, electrolyte imbalance, and musculoskeletal injury. Provider intervention is required for safety and treatment planning.
Rationale for incorrect choices:
• No murmurs noted: Absence of heart murmurs does not require reporting, as it is a normal finding and does not indicate acute risk.
• Abdomen soft and nontender to palpation: Normal abdominal assessment does not indicate acute concern. The priority is on hypoactive bowel sounds and associated gastrointestinal compromise.
Correct Answer is ["A","B","D","E","F"]
Explanation
Rationale for correct choices
• Older adult client was transferred to the ICU after developing fever and hypotension: Advanced age is a significant risk factor for delirium and altered mental status due to decreased physiological reserve, increased susceptibility to infection, and changes in cognitive function. Older adults are more vulnerable to hospital-associated stressors, medications, and sensory deficits, all of which can contribute to acute confusion. Critical illness, sepsis, and hemodynamic instability increase the risk of cerebral hypoperfusion and delirium. Fever and hypotension indicate systemic infection or shock, both of which impair oxygen delivery to the brain and can precipitate acute changes in mental status.
• Admitted 4 days ago with a left hip fracture and underwent total left hip arthroplasty: Recent surgery and immobility increase risk for delirium due to pain, anesthesia effects, infection, blood loss, and metabolic stress. Orthopedic procedures in older adults are especially high risk for postoperative cognitive changes and acute confusion.
• Past medical history: hypertension, congestive heart failure, Parkinson’s disease: Chronic cardiovascular and neurological conditions impair cerebral perfusion and neural resilience. Parkinson’s disease may already cause cognitive changes, and CHF can reduce cardiac output, increasing the likelihood of delirium during acute illness or infection.
• Visual loss without glasses: Sensory deprivation, including impaired vision, increases disorientation and confusion. Without corrective lenses, the client cannot effectively interpret environmental cues, heightening the risk of delirium and misperceptions (e.g., seeing spiders on the bed).
• Hard of hearing, hearing aids in place: Hearing impairment limits communication and environmental awareness, contributing to misinterpretation of stimuli and agitation. Even with hearing aids, the hospital environment can amplify confusion due to unfamiliar sounds and reduced auditory input. This sensory deficit is a risk factor for acute mental status changes.
Rationale for incorrect choices:
• Client is alert and oriented to person, place, and time: While this indicates baseline cognitive function, it does not contribute as a risk factor. Mental status at the time of transfer was normal, so this finding does not predispose the client to delirium. Only changes in orientation or acute stressors increase risk.
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