A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Choice A reason: Guilt-tripping with duty ignores caregiver burden, risking burnout. Scientifically, this lacks support for Alzheimer’s care, as emotional pressure doesn’t address practical needs, potentially worsening family stress and health outcomes contrary to holistic care principles.

Choice B reason: Offering respite care info supports the son, reducing stress with temporary relief options. Scientifically, this aligns with caregiver well-being research, as breaks improve mental health and sustain home care for Alzheimer’s, addressing his needs effectively.

Choice C reason: Suggesting other family help assumes availability, potentially straining dynamics without solutions. Scientifically, this shifts burden without support, less effective than respite, as it doesn’t guarantee aid or address the son’s immediate caregiving capacity.

Choice D reason: Long-term care is a major step, not initial support, and may feel dismissive. Scientifically, it skips intermediate options like respite, which better sustain home care for mild conditions, misaligning with gradual care escalation principles.

Choice A reason: Instructing another nurse to record risks errors; the receiving nurse must document directly for accuracy. Scientifically, this violates chain-of-command and transcription protocols, as firsthand recording ensures fidelity to the provider’s intent, reducing miscommunication in medication orders.

Choice B reason: Asking for spelling clarifies the medication, preventing errors like sound-alikes (e.g., Celexa vs. Celebrex). Scientifically, this aligns with safety standards, as precise identification ensures correct drug administration, critical in telephone orders where auditory mistakes are common.

Choice C reason: Withholding until signed delays care; telephone orders allow immediate action with later signature (e.g., 24-48 hours). Scientifically, this contradicts urgent care needs, as timely treatment outweighs procedural lag, provided documentation and verification are complete.

Choice D reason: Recording date and time establishes a legal timeline, ensuring accountability and sequence of care. Scientifically, this is mandatory in telephone orders, supporting traceability and adherence to protocols, critical for auditing and patient safety in medication administration.

Choice E reason: Read-back confirmation verifies accuracy, reducing errors in verbal orders. Scientifically, this is evidence-based, as it ensures the provider’s intent matches the nurse’s record, safeguarding against misheard doses or drugs, a key step in safe prescribing practices.