All of the following are safety guidelines in taking care of a patient with delirium except
Delegate visiting family members to watch delirious patient.
Never leave a patient in acute delirium alone
Used trained sitters to help with safety.
Used effective engagement techniques.
The Correct Answer is A
A. Delegate visiting family members to watch delirious patient is not a recommended safety guideline. While family members can offer support, they are not trained to monitor and manage the safety of a patient with delirium. This could also place undue stress on the family and compromise patient care.
B. Never leave a patient in acute delirium alone is a key safety guideline. Patients with delirium are at a higher risk for falls, injury, and disorientation. Close supervision is necessary to ensure their safety.
C. Use trained sitters to help with safety is a best practice. Trained sitters can ensure that the delirious patient remains safe and prevent them from wandering, falling, or becoming more agitated.
D. Use effective engagement techniques like reorientation and distraction are important in managing delirium. These techniques help to calm the patient, reduce confusion, and improve their comfort level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Confusion is a common symptom of delirium tremens (DTs). It is one of the hallmark signs of alcohol withdrawal delirium, characterized by altered mental status and disorientation.
B. Hypertension is not typically a defining symptom of delirium tremens, although it can sometimes occur in the broader context of withdrawal. However, it is not a primary feature of DTs. The more characteristic symptoms are related to neurological and autonomic disturbances, such as tremors and seizures.
C. Seizures are a well-known symptom of delirium tremens. Withdrawal from alcohol, especially after prolonged heavy use, can lead to seizures, which are a significant concern in DTs.
D. Severe tremors (or shakes) are a hallmark symptom of delirium tremens. These tremors are usually very pronounced and can affect the hands, face, or whole body.
Correct Answer is C
Explanation
A. Sweating is a common symptom of opioid withdrawal and is included in the Clinical Opiate Withdrawal Scale (COWS), which is used to assess the severity of withdrawal symptoms.
B. Goosebumps (also called piloerection) are a classic physical sign of opioid withdrawal and are specifically assessed in the COWS scoring system.
C. Palpitations are not typically listed as a core symptom of opioid withdrawal in the COWS assessment. While some individuals may subjectively report feeling anxious or having an increased heart rate, palpitations are not a primary or consistent withdrawal symptom.
D. High blood pressure is a recognized symptom of opioid withdrawal and is measured in the COWS tool as part of autonomic symptoms like increased pulse and blood pressure.
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