A nurse is collecting data from an adult client in an outpatient mental health clinic.
The nurse should identify which of the following events as a potential cause of a maturational crisis?

Choice A rationale

Providing the client with a dark environment for sleeping can aid in better rest and sleep quality, which is particularly important for clients with dementia who may have disrupted sleep patterns. However, it's essential to ensure that the environment is safe to prevent any accidents due to poor visibility.

Choice B rationale

Repeating orientation tasks until the client gives a correct response can help reinforce their memory and cognitive function. This practice is known as reality orientation, which is a therapeutic technique used to improve awareness of time, place, and person in clients with dementia.

Choice C rationale

Giving the client a list of foods to choose from for dinner provides autonomy and encourages decision-making. It helps in maintaining cognitive function and personal preferences, which can positively impact their mental health and quality of life.

Choice D rationale

Making a personal introduction to the client at each interaction helps in establishing a connection and reducing confusion. Clients with dementia often have short-term memory loss, so frequent reintroduction can provide reassurance and familiarity, contributing to their sense of security. .

Condition: Delirium.

2 actions:

Encourage family members to stay with the client,

Monitor the client's fluid intake and output.

2 parameters:

Fall risk,

Sleep-wake cycle.

Rationale for correct condition: Delirium is indicated by the sudden onset of disorientation, confusion, and changes in mental status. Postoperative status, dehydration, and infection contribute to delirium. The client's symptoms began recently and are acute. Delirium often presents with restlessness and disturbed sleep. Immediate intervention is crucial to prevent further deterioration.

Rationale for actions: Family presence provides reassurance and helps reorient the client. Familiar faces can reduce anxiety and confusion. Monitoring fluid intake and output addresses dehydration, a common delirium trigger. Ensuring proper hydration can improve mental status. Identifying coping skills is less urgent in acute delirium. Encouraging exercise is inappropriate until the client stabilizes.

Rationale for parameters: Monitoring fall risk is crucial due to the client's confusion and agitation. Preventing falls ensures safety. Tracking the sleep-wake cycle helps assess delirium severity and improvement. Delirium often disrupts sleep patterns. Suicidal ideation is less likely related to delirium. Weight loss is not an immediate concern. Oxygen saturation is stable, irrelevant for delirium.

Rationale for incorrect conditions: Depression presents with prolonged low mood, not sudden confusion. Alzheimer's disease involves gradual cognitive decline, unlike acute delirium. Generalized anxiety disorder does not explain acute disorientation and restlessness.