A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?

Patient will remain safe in the environment

Patient will acknowledge reality.

Patent will communicate verbally.

Patient will participate actively in self-care

Answer and Explanation

The Correct Answer is A

A. Patient will remain safe in the environment is the priority outcome in both delirium and dementia scenarios. In both conditions, the patient is at an increased risk of harm due to confusion, misinterpretation of reality, and impaired judgment. Ensuring the patient's safety is the first and foremost concern. This could involve managing the patient's environment, preventing falls, using safety measures like bed alarms, and ensuring that wandering is minimized.
B. Patient will acknowledge reality is a desirable goal but not the immediate priority in these cases. In delirium, the patient's altered reality is typically reversible once the underlying cause is addressed. In dementia, reality orientation may be difficult or impossible to fully achieve, so safety is more important.
C. Patient will communicate verbally is important, but in these cases, the patient's safety is more critical. Communication abilities may vary depending on the severity of the delirium or dementia, and focusing on verbal communication may not address the more immediate need for safety.
D. Patient will participate actively in self-care is an important goal for promoting independence, but in the case of delirium and dementia, ensuring the patient's safety must be prioritized first, as these conditions may impair the patient's ability to perform self-care activities safely.

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Correct Answer is B

Explanation

A. Limit conversations and redirect to complete ADLs may be too restrictive and does not support therapeutic communication. While redirection can be helpful, limiting conversations may increase confusion and isolation in patients with Alzheimer's disease.
B. Use short, simple words and phrases is the most effective communication strategy. Patients with Alzheimer's disease often have difficulty processing complex information, so clear, simple, and concise language helps them better understand and reduces frustration.
C. Confront patient’s delusions and provide reality orientation is not recommended. Confronting delusions can lead to increased agitation and distress. A more supportive approach, such as using validation therapy or gentle redirection, is typically more therapeutic.
D. Talk with the patient about abstract ideas is not appropriate. Individuals with Alzheimer's often have difficulty understanding abstract concepts. Concrete, straightforward communication is more effective for maintaining engagement and reducing confusion.

A. Physical or chemical means or device that restricts client's freedom to and ability to move about B. The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. C. Pharmacological interventions for management of acute behavioral emergencies D. Safety measures to prevent a threatened or attempted suicide or some serious bodily injury

Correct Answer is A

Explanation

A. Physical or chemical means or device that restricts client's freedom to and ability to move about is the most accurate definition of restraint. This includes any method or device used to prevent a patient from moving freely, such as physical devices (like straps or handcuffs) or chemical restraints (medications used to sedate or calm the patient).
B. The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving refers to seclusion, not restraints. Seclusion is a form of isolation, often used when a patient is a danger to themselves or others, but it is distinct from restraints.
C. Pharmacological interventions for management of acute behavioral emergencies refers to the use of medication, but this is not specifically a restraint. Restraints involve preventing movement or controlling behavior through either physical or chemical means, but this definition is more about the use of medication in emergencies rather than restricting movement.
D. Safety measures to prevent a threatened or attempted suicide or some serious bodily injury describes precautionary measures rather than the definition of restraint itself. Restraints are about restricting movement, not necessarily about preventing injury or harm directly.

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A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following interventions should be incorporated into the care of patient diagnosed with Alzheimer's disease?

Correct Answer is B

Explanation

Which of the following statements best define the term "restraint"

Correct Answer is A

Explanation

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