A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

The correct answer is choice B.

Choice A rationale:

A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.

Choice B rationale:

A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.

Choice C rationale:

A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.

Choice D rationale:

A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.

The correct answer is choice D.

Choice A rationale:

Encouraging the family to take the client out of the facility for short periods of time may not be appropriate at this point. Abrupt changes in behavior, like sudden cheerfulness, might be a warning sign for potential suicide risk in individuals with depression. Allowing the client to leave the facility could increase the risk of harm.

Choice B rationale:

Rewarding the client for the change in behavior might inadvertently reinforce the idea that acting cheerful is desirable. This could hinder the client's progress and therapeutic understanding of their condition.

Choice C rationale:

Asking the client why her behavior has changed is a thoughtful and reasonable approach, but it might not address the potential underlying issues adequately. Depression can still be present, and sudden shifts in mood should be monitored closely.

Choice D rationale:

Monitoring the client's whereabouts at all times is the appropriate action. Sudden improvements in a depressed client's demeanor could indicate that they have made a decision to end their life. Monitoring ensures their safety and enables prompt intervention if needed.