A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
Alternate daily caregivers.
Remind the client of the day and time often.
Offer the client several choices at mealtimes.
Avoid discussing the client's fears.
The Correct Answer is B
A. Alternate daily caregivers is incorrect. Consistent caregiving is important for clients experiencing delirium to provide stability and reduce confusion. Frequent changes in caregivers can increase anxiety and disorientation.
B. Remind the client of the day and time often is correct. Frequent reminders of the day, time, and orientation help ground the client in reality and reduce confusion. This is an essential part of managing delirium by addressing disorientation and improving cognitive clarity.
C. Offer the client several choices at mealtimes is incorrect. Giving too many choices can lead to overwhelm and confusion in clients with delirium. It is better to offer simple, limited options to avoid stress or difficulty in decision-making.
D. Avoid discussing the client's fears is incorrect. Addressing a client's fears is important in the management of delirium. It is more beneficial to acknowledge and provide reassurance, which can help reduce anxiety and the psychological stress that might exacerbate delirium.
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Related Questions
Correct Answer is D
Explanation
A. Expressing conflict over independence and control is incorrect. This behavior is more characteristic of adolescents, who struggle with autonomy as they develop their identity. Nine-year-old children are still largely influenced by parents and rules.
B. Demonstrating self-centered thinking is incorrect. Egocentric thinking is typical in preschool-aged children, while school-aged children develop the ability to see other perspectives and think more logically.
C. Displaying emotional detachment from parents is incorrect. While school-aged children begin to form peer relationships, they typically maintain strong emotional connections with their parents rather than detaching from them.
D. Grasping the concept of cause-and-effect is correct. At this stage, children develop logical thinking and an understanding of consequences, allowing them to recognize how actions lead to specific outcomes.
Correct Answer is D
Explanation
A. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.
B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.
C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.
D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.
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