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?
Remind the client of the day and time often.
Offer the client several choices at mealtimes.
Avoid discussing the client's fears.
Alternate daily caregivers.
The Correct Answer is A
A. Correct.
Option A, reminding the client of the day and time often, aligns with this goal. Orienting the individual to time and place can help reduce confusion and disorientation commonly associated with delirium.
B. Incorrect. Offering the client several choices at mealtimes, might not directly address the issue of orientation and may potentially overwhelm the individual, exacerbating their confusion.
C. Incorrect. Discussing the client's fears and addressing their concerns is important for providing appropriate care and support.
D. Incorrect. Alternating daily caregivers may increase confusion for the client experiencing delirium. Consistency in care providers can be beneficial.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Remaining in bed until falling asleep can worsen insomnia and create negative associations with the bed.
B. While maintaining a consistent sleep schedule is important, sleeping longer on the weekends can disrupt the circadian rhythm.
C. Keeping the television volume low can help with sleep, but it might not directly address the underlying issue of trouble falling asleep.
D. Correct. Regular exercise, especially during the day, can help regulate sleep patterns and improve the ability to fall asleep at night.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Given the client's symptoms (productive cough, blood-tinged sputum, fatigue, night sweats, low-grade fever, weight loss, and recent travel to South Africa), there is a suspicion of tuberculosis (TB). The Mantoux test (a skin test for TB) and a chest X-ray are appropriate diagnostic tools to evaluate for TB.
A. a nasopharyngeal swab: This test is used to detect respiratory infections, but the client's symptoms and history do not specifically indicate the need for this test.
B. A pulmonary function test: While this test assesses lung function, it may not be the initial choice for evaluating the presented symptoms and history.
C. A chest x-ray
Rationale: Given the client's symptoms of cough, fatigue, night sweats, low-grade fever, and blood-tinged sputum, a chest x-ray is indicated to assess the condition of the lungs and potential underlying respiratory issues.
D. blood cultures
Rationale: The client's symptoms, including fever, could indicate an underlying infection. Blood cultures are used to identify potential bacterial or fungal infections in the bloodstream, but this is not likely for this patient
E. a Mantoux test
Rationale: The client's recent travel history, cough, and weight loss may prompt consideration of a tuberculosis (TB) infection. A Mantoux test is a common initial screening tool for TB exposure.
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