A nurse is educating a group of nursing students about brain herniation.
Which of the following interventions should the nurse include as a potential treatment for brain herniation?

Choice A rationale

Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.

Choice B rationale

Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.

Choice C rationale

While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.

Choice D rationale

Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.

Step 1: Convert All Fluid Intake to Milliliters (mL)

To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:

• 1 cup of coffee = 240 mL
• 4 oz of orange juice = 118.3 mL
• 3 oz of water = 88.7 mL
• 1 cup of flavored gelatin = 236.6 mL
• 1 cup of tea = 240 mL
• 5 oz of broth = 147.9 mL
• 3 oz of water (another serving) = 88.7 mL

Step 2: Calculate Total Fluid Intake

Add all the converted fluid amounts together:

• Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL

Step 3: Round to the Nearest Whole Number

Round the total to the nearest whole number:

• Rounded total = 1,160 mL

The nurse should record 1,160 mL on the patient’s chart.