A nurse is assessing a client who has Alzheimer’s disease. Which of the following findings should the nurse identify as the priority?

Choice A reason: Delirium, an acute confusional state, impairs orientation to time, place, and person. A calendar provides a visual cue to reinforce temporal orientation, reducing confusion and agitation. This non-pharmacological intervention supports cognitive grounding, helping stabilize the client’s mental status during acute delirium episodes.

Choice B reason: Refuting hallucinations can increase agitation in delirium, as clients may feel invalidated. Hallucinations result from altered brain function, often due to metabolic or infectious causes. Acknowledging the client’s experience while redirecting focus is safer, as confrontation may escalate distress or confusion.

Choice C reason: Teaching assertive techniques is inappropriate for delirium, as clients have impaired cognition and cannot process complex instructions. Assertiveness training is better suited for chronic mental health conditions like personality disorders, not acute delirium, which requires immediate stabilization of cognitive and physiological disturbances.

Choice D reason: Assigning different caregivers each shift can worsen confusion in delirium, as consistency fosters familiarity and reduces anxiety. Delirium’s fluctuating cognitive state benefits from stable caregiving, which helps maintain a calm environment and supports recovery from underlying causes like infection or electrolyte imbalance.

Choice A reason: Staying for 15 minutes post-meal is insufficient to prevent purging in anorexia nervosa, as clients may delay vomiting. Supervision for 30–60 minutes is standard to ensure nutritional retention, addressing the disorder’s characteristic behaviors driven by distorted body image and restrictive eating patterns.

Choice B reason: A daily exercise program is contraindicated in acute anorexia nervosa, as excessive activity exacerbates malnutrition and cardiac strain. Rest is prioritized to conserve energy and support weight restoration, addressing the severe caloric deficit and metabolic complications associated with the disorder’s restrictive behaviors.

Choice C reason: Discussing food during meals can increase anxiety in anorexia nervosa, as clients have intense food-related fears. Neutral conversation reduces distress, supporting nutritional intake. Food-focused talk reinforces obsessive thoughts, counteracting therapeutic goals to normalize eating behaviors and address psychological distortions.

Choice D reason: Daily weighing in acute care monitors nutritional progress in anorexia nervosa, ensuring weight restoration and guiding treatment. Consistent weights assess response to refeeding, addressing severe malnutrition risks like cardiac arrhythmias. Standardized protocols (e.g., morning post-void) ensure accuracy, making this critical for medical stabilization.