A nurse is caring for a client who was admitted with delirium five days ago. The client seeks permission from the nurse before performing ADLs. Which of the following actions should the nurse take?
Quiz the client with orientation questions.
Allow the client to function independently.
Prepare the client for discharge.
Determine the client's level of awareness.
The Correct Answer is D
A: Quizzing the client might be part of an assessment but not the initial action.
B: Allowing independent function is important, but assessing cognitive function to tailor support is essential first.
C: Preparing for discharge might be premature without assessing readiness and stability.
D: Assessing awareness and cognitive function helps guide appropriate support and independence levels.
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Related Questions
Correct Answer is C
Explanation
A: While counseling may eventually be helpful, initially encouraging the partner to express his difficulties provides immediate emotional support and can help assess the needs more clearly.
B: Calling a family meeting may be beneficial, but first understanding the specific struggles can help inform what help is needed from family members.
C: This approach allows the nurse to gather more information about the partner's specific struggles and provide tailored support and resources.
D: Recommending placement in a long-term care facility might eventually be necessary, but it should follow an assessment and discussion of all options and supports available.
Correct Answer is B
Explanation
A: Incoherent speech is more typical of severe anxiety.
B: Irritability can be a symptom of mild anxiety, where the person may have heightened awareness but still maintains coherence and function.
C: Insomnia is generally associated with more chronic or severe states of anxiety.
D: Chest pain is usually associated with more severe forms of anxiety, such as panic attacks.
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