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. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).
B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.
C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.
D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.
Correct Answer is B
Explanation
A. "Provide homeschooling for your child" is not a necessary instruction. Children with cystic fibrosis can attend school, and with appropriate care, they can often manage their condition and participate in normal activities.
B. "Have your child wear a medical identification wristband" is correct. A medical identification wristband is important for children with cystic fibrosis as it can provide crucial information in an emergency, such as their diagnosis and specific care needs.
C. "Ensure that your child does not receive the influenza vaccine annually" is incorrect. Children with cystic fibrosis are at higher risk for respiratory complications and should receive the influenza vaccine annually to help prevent infection and reduce the risk of exacerbations.
D. "Do not include your child when making decisions about treatment" is incorrect. Involving children in their treatment decisions, as appropriate for their age and understanding, is important for fostering autonomy and ensuring they feel empowered in managing their condition.
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