A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?
Promote decision making about care.
Discourage visits from significant others
Provide environmental cues.
Apply physical restraints.
The Correct Answer is C
Choice A reason:
The statement "Promote decision making about care" is not appropriate for a client experiencing delirium. Delirium can cause confusion, disorientation, and impaired decision-making abilities. Encouraging the client to make decisions about their care may increase their anxiety and confusion.
Choice B reason:
The statement "Discourage visits from significant others" is not advisable. Visits from familiar people can provide comfort and reassurance to a client experiencing delirium. Isolation can exacerbate feelings of confusion and distress.
Choice C reason:
The statement "Provide environmental cues" is the correct response. Environmental cues, such as clocks, calendars, and familiar objects, can help orient the client and reduce confusion. Maintaining a consistent routine and minimizing environmental changes can also promote safety and comfort.
Choice D reason:
The statement "Apply physical restraints" is not recommended as a first-line intervention. Physical restraints can increase agitation and the risk of injury. They should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The statement "Rapid mood swings" is not typically associated with Alzheimer's disease. While mood changes can occur, they are usually more gradual and related to frustration or confusion rather than rapid swings. Alzheimer's disease primarily affects memory and cognitive functions, leading to progressive decline in these areas.
Choice B reason:
The statement "Excessive motor activity" is not a common finding in Alzheimer's disease. Patients with Alzheimer's may experience restlessness or wandering, but excessive motor activity is more characteristic of other conditions such as mania or certain types of dementia.
Choice C reason:
The statement "Altered level of consciousness" is not a typical symptom of Alzheimer's disease. Alzheimer's patients usually maintain a normal level of consciousness until the later stages of the disease, where severe cognitive decline can lead to reduced awareness. Altered level of consciousness is more commonly associated with acute conditions such as delirium or other neurological disorders.
Choice D reason:
The statement "Failure to recognize familiar objects" is the correct response. This symptom, known as agnosia, is a hallmark of Alzheimer's disease. As the disease progresses, patients often lose the ability to recognize familiar objects, people, and places, which significantly impacts their daily functioning and independence.
Correct Answer is C
Explanation
Choice A Reason:
Verbalizing an improved mood is a positive outcome, but it is not specific to borderline personality disorder (BPD). Clients with BPD often struggle with interpersonal relationships and emotional regulation. While mood improvement is beneficial, it does not directly address the core issues of BPD, such as difficulty in expressing needs and managing relationships.
Choice B Reason:
Attending to personal hygiene is important for overall health and well-being, but it is not a primary focus in the treatment of BPD. Clients with BPD may have issues with self-care during depressive episodes, but the primary treatment goals usually revolve around emotional regulation, interpersonal effectiveness, and distress tolerance.
Choice C Reason:
Communicating needs is a crucial outcome for clients with BPD. One of the core challenges in BPD is difficulty in expressing emotions and needs effectively, which often leads to interpersonal conflicts and emotional distress. Improving communication skills can help clients build healthier relationships and manage their emotions more effectively. This outcome aligns with therapeutic goals in treatments like Dialectical Behavior Therapy (DBT), which focuses on enhancing interpersonal effectiveness.
Choice D Reason:
Reporting a decrease in hallucinations is not typically associated with BPD. Hallucinations are more commonly linked to psychotic disorders such as schizophrenia. While some clients with BPD may experience transient psychotic symptoms under extreme stress, these are not the primary focus of treatment. The main treatment goals for BPD involve managing emotional dysregulation and improving interpersonal relationships.
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