A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

The correct answer is c.

Choice A Reason:

The statement “I am glad I’m getting out of here. I shouldn’t be here anyway.” indicates a lack of insight into the need for treatment and does not demonstrate readiness for discharge. Clients who are ready for discharge typically acknowledge their condition and the importance of ongoing care. This statement suggests denial or minimization of the issues that led to hospitalization, which can be a barrier to successful discharge and continued recovery1.

Choice B Reason:

The statement “I know I’m ready to go. I’ve got everything under control.” can be misleading. While it may seem positive, it lacks specific details about the client’s discharge plan and follow-up care. Readiness for discharge involves more than just feeling ready; it requires a concrete plan for managing medications, follow-up appointments, and support systems. Without these details, the statement does not fully indicate readiness for discharge.

Choice C Reason:

The statement “I have a list of my medications and have made an appointment with my doctor.” is correct. This statement demonstrates that the client has a clear understanding of their medication regimen and has taken proactive steps to ensure continuity of care after discharge. Having a follow-up appointment scheduled is a critical component of discharge planning, as it helps ensure that the client will continue to receive necessary support and monitoring. This level of preparation indicates that the client is ready for discharge.

Choice D Reason:

The statement “I just can’t get rid of these thoughts about dying.” is a serious concern and indicates that the client is not ready for discharge. Persistent thoughts of dying or suicidal ideation require immediate attention and intervention. Discharging a client with these thoughts would be unsafe and could lead to severe consequences. The client needs further evaluation and treatment to address these thoughts before being considered for discharge.

Choice A Reason:

“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”

This response is the most supportive because it acknowledges the client’s feelings and offers a proactive solution. By recognizing the difficulty of the transition and suggesting a plan to ensure the client’s safety, the nurse provides reassurance and practical support. This approach helps to build trust and shows empathy, which is crucial in a therapeutic relationship.

Choice B Reason:

“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”

While this response acknowledges the client’s fear, it focuses on policy rather than addressing the client’s immediate emotional needs. Extending the stay might not be feasible or beneficial in the long term. The primary goal should be to empower the client to feel safe and supported outside the facility.

Choice C Reason:

“You’ve had a month to come up with a plan to work on your well-being.”

This response can come across as dismissive and unsupportive. It implies that the client should have already resolved their fears, which may increase their anxiety and feelings of inadequacy. The focus should be on providing immediate support and reassurance rather than criticizing the client’s progress.

Choice D Reason:

“Hopefully you learned from being in counseling. I’m sure this will work out fine.”

This response is overly optimistic and does not address the client’s current fears. It provides false reassurance without offering any concrete support or solutions. The client needs to feel heard and supported, not just reassured that everything will be fine.