A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

A. This option is not appropriate for a client with acute delirium. Delirium is characterized by fluctuating levels of consciousness, attention, and cognition. High-stimulation environments, such as loud noises or bright lights, can exacerbate confusion and agitation in these clients. Therefore, providing a calm and quiet environment is crucial to help reduce symptoms of delirium.
B. Delirium can often be worsened during nighttime due to factors like disruption of sleep-wake cycles and disorientation in a new environment. Keeping the client's room dark at night helps to promote rest and reduce disturbances. However, this is not the most important intervention.

C. Family support and presence are typically beneficial for clients, even those with delirium. Family members can provide familiarity, comfort, and assistance in reorienting the client. Discouraging visitation would not be appropriate unless the family members are contributing to increased agitation or confusion. Instead, it's important to educate family members on how to interact with and support the client effectively.
D. Clients with delirium often experience impaired cognition, making decision-making challenging for them. Limiting the client's need to make decisions can help reduce their stress and frustration. It's important for the nurse to simplify choices when possible and provide guidance and support as needed. This approach can help alleviate cognitive load and improve the client's ability to cope.