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 C
Explanation
A. Documenting in the nursing care plan is incorrect. The nursing care plan outlines interventions and client needs, but it is not used for documenting medication errors.
B. Recording in the controlled substance inventory record is incorrect. While the administration of a controlled substance must be recorded, the inventory record tracks medication usage and does not serve as documentation for errors.
C. Completing an incident report is correct. An incident report is used to document medication errors, allowing for review and quality improvement measures to prevent future occurrences.
D. Writing in the provider's progress notes is incorrect. The provider's progress notes focus on client status and treatment plans, not internal error reporting. However, the nurse should notify the provider about the error.
Correct Answer is B
Explanation
A. Eating three large meals and two snacks per day is not advisable for GERD patients. Large meals can increase the pressure on the lower esophageal sphincter (LES), leading to acid reflux. It is better to recommend smaller, more frequent meals to reduce symptoms.
B. Elevating the head of the bed while sleeping is correct. Elevating the head of the bed (usually by 6 to 8 inches) helps prevent acid from refluxing into the esophagus during sleep, a key management strategy for GERD.
C. Laying down for 1 hour following a meal is incorrect. After eating, patients with GERD should avoid lying down for at least 2 to 3 hours to prevent acid reflux. Lying down too soon after eating increases the risk of reflux.
D. Drinking 2 cups of coffee per day is not ideal for people with GERD, as caffeine can relax the LES, leading to increased reflux. While the exact amount varies by individual tolerance, it is generally recommended to limit or avoid caffeine.
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