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.
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Related Questions
Correct Answer is A
Explanation
A. Provide positive reinforcement when the child uses eye contact: Positive reinforcement is an effective strategy for children with autism, especially for improving communication behaviors like eye contact. It encourages social interaction in a non-overwhelming way.
B. Administer haloperidol to the child as prescribed: Haloperidol is an antipsychotic used for certain symptoms in ASD, but its use should be carefully monitored. Medication is not the first line for addressing communication challenges in children with ASD.
C. Administer tranquilizing medications if the child becomes frustrated: Using tranquilizing medications as a first response is inappropriate. Non-pharmacological approaches, like behavior modification, should be prioritized to manage frustration and other symptoms.
D. Instruct the child's guardian on the use of implosion therapy: Implosion therapy, which involves exposing the child to anxiety-provoking situations, is not appropriate for children with ASD. It can increase distress and is not suitable for managing the child's needs.
Correct Answer is C
Explanation
A. "We will help get you through this. You'll be fine.": While this statement may be meant to comfort, it dismisses the client's feelings and doesn't address the possibility of immediate harm or crisis. It’s important to validate the client’s emotions and assess for safety.
B. "What have you done to change your situation?": This response can come across as accusatory or judgmental, which may not be helpful in a crisis situation. It’s important to be supportive and nonjudgmental rather than questioning the client’s actions.
C. "Are you thinking about harming yourself?": The client's statement indicates feelings of hopelessness, which could signal suicidal ideation. Directly asking about self-harm or suicide helps assess the client's safety and provides an opportunity to intervene if necessary.
D. "You should remove yourself from this situation now.": While suggesting safety is important, this statement may feel too directive or overwhelming. The nurse should assess the client’s readiness for action and help them explore their options in a supportive way.
Complete the following sentence by using the lists of options.
The client is at risk of developing