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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. "It is your choice to share personal information during group therapy" is correct. The ethical principle of autonomy emphasizes respecting a client's right to make decisions about their own care, including the right to share or withhold personal information. Allowing the client to choose what to share supports their independence and decision-making ability.

B. "I will be truthful when answering questions about your treatment" promotes veracity, not autonomy. While truthfulness is important in nursing, it does not directly pertain to the principle of client autonomy.

C. "The nursing staff here will provide you with nonjudgmental care" promotes beneficence and respect for the client's dignity, but it does not directly address the principle of autonomy, which focuses on the client’s ability to make choices.

D. "I will only discuss your medical information with the health care team" supports confidentiality and privacy, not autonomy. Autonomy involves respecting a client’s decision-making, not just protecting their information.

A. Check the client's skin every 4 hr. B. Place a donut-shaped cushion under the client. C. Turn the client every/hr. D. Place the client in a 30° lateral position.

Correct Answer is D

Explanation

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

Explanation

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