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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.
Correct Answer is C
Explanation
A. Incorrect. Opening the fireplace dampers may allow external contaminants to enter the facility and is not recommended during an external chemical disaster.
B. Incorrect. Covering electrical outlets with wet towels may not provide effective protection against chemical contaminants and is not a recommended action.
C. Correct. Moving clients to a room above ground with few windows helps protect them from potential exposure to external chemical contaminants. Windows can allow contaminants to enter, and an aboveground location can reduce the risk of exposure.
D. Incorrect. Turning on fans may circulate contaminated air throughout the facility and is not recommended during a chemical disaster.
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