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 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.
Correct Answer is A
Explanation
A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.
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