A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan?

Assign the client to a different caregiver each shift.

Teach the client assertive techniques.

Refute the client's perception of visual hallucinations

Reinforce the client's orientation with a calendar.

Answer and Explanation

The Correct Answer is D

A. Assign the client to a different caregiver each shift: This is not ideal for a client with acute delirium. Consistency in caregivers is important to reduce confusion and help the client feel more secure in a familiar environment.

B. Teach the client assertive techniques: Assertiveness training is more appropriate for clients with anxiety or communication difficulties, not for those with acute delirium. In delirium, the priority is managing cognitive function and safety.

C. Refute the client's perception of visual hallucinations: Refuting hallucinations can cause frustration and worsen the client's confusion. It’s better to acknowledge the hallucinations calmly without validating them, offering reassurance instead of confrontation.

D. Reinforce the client's orientation with a calendar: This is an appropriate intervention. Using a calendar, clock, and other orientation tools helps reinforce reality and can reduce confusion in clients with delirium, aiding in their cognitive stabilization.

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Correct Answer is B

Explanation

Rationale for correct choice:

Determine the client's level of anxiety to check for the risk of self-harm: Assessing the client’s anxiety is vital in identifying any risk of self-harm or suicidal thoughts, especially after trauma. This helps the nurse provide appropriate interventions to ensure the client's safety.

Rationale for incorrect choices:

Tell the client their consent is not required prior to collecting potential physical evidence: The nurse must obtain the client’s consent before collecting any physical evidence. Consent is a legal and ethical requirement, especially in cases of sexual assault.
Ask the client if they often walk alone when out in public places: This question may inadvertently lead to feelings of guilt or self-blame and is not an immediate priority. The focus should be on addressing the trauma and the client's current needs.
Avoid asking the client open-ended questions during the interview: Open-ended questions allow the client to express their feelings and experiences, which is essential in trauma care. Avoiding them could hinder the client’s ability to share and may limit the nurse’s understanding of the situation.

A. "Nicotine causes an increase in blood pressure." B. "Anabolic steroids stimulate the immune system." C. "Methamphetamine causes weight gain." D. "Amphetamines alleviate symptoms of depression."

Correct Answer is A

Explanation

A. "Nicotine causes an increase in blood pressure.": Nicotine is a stimulant that can constrict blood vessels, leading to an increase in blood pressure and heart rate. It is one of the known cardiovascular effects of smoking.

B. "Anabolic steroids stimulate the immune system.": Anabolic steroids can actually have a suppressive effect on the immune system, making users more susceptible to infections. Their primary effects are on muscle growth and secondary male characteristics.

C. "Methamphetamine causes weight gain.": Methamphetamine is a stimulant that typically causes weight loss, not weight gain, due to its appetite-suppressing effects and increased metabolism.

D. "Amphetamines alleviate symptoms of depression.": While amphetamines can temporarily improve mood and increase energy, they are not a primary or safe treatment for depression.as can lead to dependence, making them inappropriate for long-term management of depression.

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A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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