A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?
Have the client sit by the nurse's desk while awake in a room with the television on
Provide a well-lit room without glare or shadows and limit noise
Keep the room shadowy with soft lighting around the clock, and keep a radio on continuously
Light the room brightly around the clock and awaken hourly to check mental status
The Correct Answer is B
B. This option promotes a calming and supportive environment that minimizes sensory stimuli and helps maintain orientation, reducing the risk of exacerbating symptoms of delirium and illusions.
A. Having the client sit by the nurse's desk may provide some supervision and reassurance, but keeping the television on can contribute to sensory overload and increase confusion, especially if the client is experiencing illusions.
C. Keeping the room shadowy with soft lighting and continuously playing a radio may create an environment that is disorienting and confusing for the client with delirium.
D. Maintaining bright lighting around the clock may disrupt the client's sleep-wake cycle and exacerbate symptoms of delirium. Interrupting the client's sleep by awakening hourly for mental status checks can also contribute to sleep deprivation and increase agitation and confusion
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Correct Answer is D
Explanation
D. By offering assistance with getting ready and framing participation in activities as a manageable task, the nurse can help the client overcome feelings of inertia and initiate engagement. It acknowledges the client's current difficulties while providing gentle encouragement to participate in the unit's programs.
A. This response may come across as dismissive of the client's feelings and struggles. It may also increase feelings of guilt or inadequacy in the client, potentially worsening their depressive symptoms.
B. It offers support without pressure and allows the client to take the initiative when they feel comfortable to engage in activities. However, it may not provide enough encouragement or assistance for the client to overcome their depressive symptoms and initiate activity.
C. Encouraging prolonged withdrawal from activities without offering support or motivation to engage may contribute to further isolation and exacerbate depressive symptoms.
Correct Answer is B
Explanation
A. A structured environment can include regular meal times, consistent routines, and clear expectations. While providing a structured environment is important in the overall management of eating disorders, it may not address the immediate concerns related to the client's severe weight loss and distorted body image.
B. Given the client's significant weight loss and distorted body image, assessing their nutritional status is crucial in understanding the extent of the problem and determining appropriateinterventions.
interventions. However, the client’s symptoms point to a mental health problem.
C. While planning a therapeutic diet is an essential component of the client's long-term treatment plan, it may not be the first priority given the client's current medical and psychological status.
D.Given the client's distorted body image, severe weight loss, and belief that she is fat, requesting a mental health consult is not the first priority. The physiological needs should be addressed first
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