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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Related Questions
Correct Answer is D
Explanation
D. Remaining with the client provides support and reassurance during a period of agitation and restlessness. The presence of the nurse can help the client feel safe and supported, and it allows the nurse to assess the client's condition closely and intervene as needed.
A. While administering a PRN (as needed) sleeping medication may be considered in some situations, it is not the first-line intervention when a client is experiencing agitation and restlessness.
B. Encouraging the client to return to bed may be appropriate if they are willing and able to do so. However, if the client is agitated and pacing the floor, they may not feel comfortable or able to go back to bed.
C. Exploring alternatives to pacing the floor involves assessing the client's needs and preferences and identifying activities or strategies that may help alleviate agitation and promote relaxation. However, proper observation of the client behavior should be prioritized.
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing frequent meals and snacks is generally beneficial, it’s essential to focus on nutritious options.
C. Manic episodes can lead to impulsive behavior, increased activity, and risk-taking. Close monitoring ensures early detection of any safety concerns, such as self-harm or aggression.
D. Manic clients are often hypersensitive to stimuli, and a calm, low-stimulation environment can help reduce agitation and prevent exacerbation of symptoms.
E. While adequate rest is essential, discouraging daytime naps may help regulate the client’s sleep patterns and prevent excessive energy levels associated with mania.
B. Regular weight monitoring is essential for assessing overall health, but it may not be a priority specifically related to mania.
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