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 D
Explanation
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.
Correct Answer is C
Explanation
A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.
B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.
C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.
D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.
Complete the following sentence by using the lists of options.
The client is at risk of developing