A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

A. This option is not appropriate for a client with acute delirium. Delirium is characterized by fluctuating levels of consciousness, attention, and cognition. High-stimulation environments, such as loud noises or bright lights, can exacerbate confusion and agitation in these clients. Therefore, providing a calm and quiet environment is crucial to help reduce symptoms of delirium.
B. Delirium can often be worsened during nighttime due to factors like disruption of sleep-wake cycles and disorientation in a new environment. Keeping the client's room dark at night helps to promote rest and reduce disturbances. However, this is not the most important intervention.

C. Family support and presence are typically beneficial for clients, even those with delirium. Family members can provide familiarity, comfort, and assistance in reorienting the client. Discouraging visitation would not be appropriate unless the family members are contributing to increased agitation or confusion. Instead, it's important to educate family members on how to interact with and support the client effectively.
D. Clients with delirium often experience impaired cognition, making decision-making challenging for them. Limiting the client's need to make decisions can help reduce their stress and frustration. It's important for the nurse to simplify choices when possible and provide guidance and support as needed. This approach can help alleviate cognitive load and improve the client's ability to cope.

A. Consuming alcohol close to bedtime can disrupt sleep patterns. While alcohol may initially induce drowsiness, it often leads to fragmented and poor-quality sleep later in the night. Therefore, advising the client to drink alcohol before bedtime is not recommended.
B. Taking long or late-afternoon naps can interfere with nighttime sleep patterns, especially for individuals experiencing insomnia or sleep disturbances related to depression. Napping can make it harder to fall asleep or stay asleep at night, thereby exacerbating sleep problems rather than improving them.
C. Eating a large or heavy meal just before bedtime can lead to discomfort, indigestion, and even heartburn, which can interfere with falling asleep and staying asleep. It's generally advisable to avoid heavy meals close to bedtime to promote better sleep quality.
D. Caffeine is a stimulant that can interfere with sleep. Consuming caffeinated beverages, especially in the afternoon or evening, can make it difficult for individuals with depression to fall asleep and can contribute to fragmented sleep. Limiting caffeine intake earlier in the day can help promote better sleep hygiene.