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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.

A. Occupational therapy B. Palliative care C. Respite care D. Hospice care

Correct Answer is C

Explanation

A. Occupational therapy: Occupational therapy focuses on helping clients improve their ability to perform daily activities. While beneficial for individuals with Alzheimer's, it does not specifically address the partner’s need for temporary relief from caregiving duties.
B. Palliative care: Palliative care focuses on providing relief from symptoms and improving the quality of life for clients with serious illnesses. While appropriate for end-of-life care, it may not address the partner’s immediate need for respite from caregiving.
C. Respite care: Respite care provides temporary relief for caregivers by allowing them to take a break while ensuring their loved one continues to receive appropriate care. This is the most appropriate referral for the partner, who is seeking time for themselves.
D. Hospice care: Hospice care is focused on end-of-life care, offering comfort and support for clients with terminal illnesses. It is not the best option in this case, as the client is not necessarily at the end of life but has Alzheimer's disease, which is a progressive condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

Correct Answer is B

Explanation

A nurse is performing a home visit on a client who has Alzheimer's disease and their partner. The partner states, "I wish I had some time to myself and run errands, but I need to be here all the time." Which of the following referrals should the nurse recommend to the client's partner?

Correct Answer is C

Explanation

A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?

A nurse is assisting a provider in obtaining informed consent from a client who has depressive disorder and is scheduled to have electroconvulsive therapy (ECT). The signature of the nurse on the consent form indicates which of the following?

A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has schizophrenia and is preparing for discharge. Exhibits The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?

Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

A nurse at a community health center is preparing a presentation on alcohol use disorder. Which of the following risk factors should the nurse include in the presentation?