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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fatigue: Fatigue is a common symptom of cocaine withdrawal, as the body adjusts to the absence of the stimulant. Clients often feel extremely tired or lethargic during this phase. Depressive symptoms that accompany withdrawal can also contribute to feelings of exhaustion.
B. Hand tremors: Hand tremors are more often seen with alcohol withdrawal or neurological disorders. While tremors can occur in some cases, they are not a typical manifestation of cocaine withdrawal. The focus is more on mood and energy changes.
C. Rapid speech: Rapid speech is a sign of cocaine intoxication, not withdrawal. During withdrawal, clients tend to experience slowed speech and cognitive dulling, not the heightened energy associated with the drug.
D. Seizures: Seizures are more related to cocaine overdose or intoxication, not withdrawal. Withdrawal typically involves mood changes and fatigue rather than physical manifestations like seizures.
Correct Answer is B
Explanation
A. Institute consequences for deliberate behaviors: While consequences can help manage behaviors, focusing on punishment alone is not the most effective approach for ADHD. Positive reinforcement is often more beneficial.
B. Encourage thought stopping techniques: Thought-stopping techniques help children with ADHD manage impulsive behaviors and improve focus. They teach self-regulation by interrupting unwanted thoughts.
C. Administer olanzapine: Olanzapine is an a typical antipsychotic, not a treatment for ADHD. Stimulants like methylphenidate or amphetamines are typically used for ADHD management.
D. Provide a stimulating environment: A stimulating environment can worsen distractions for children with ADHD. A structured, quiet environment helps improve focus and reduces impulsivity.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.