The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply)

Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.

Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.

Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.

Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.

Choice A reason: Jumping in to provide patient comfort, while well-intentioned, implies reactive or task-oriented actions rather than the intentional, empathetic engagement of presence. Presence involves being emotionally available, fostering trust and connection, not just addressing immediate physical needs. This choice risks misrepresenting the holistic, relational aspect of presence critical for patient and family support.

Choice B reason: Being there without an identified goal does not fully capture presence, which is purposeful in fostering emotional and spiritual support. Presence involves intentional closeness and caring, not aimless attendance. This choice underestimates the nurse’s role in creating a therapeutic environment, potentially diminishing the impact of presence on patient and family well-being.

Choice C reason: Focusing on tasks prioritizes technical care over emotional connection, contrary to presence, which emphasizes being with the patient holistically. Task-oriented care may address physical needs but neglects the relational support central to presence. This choice misaligns with the concept, risking a purely functional approach that overlooks emotional and spiritual care needs.

Choice D reason: Providing closeness and a sense of caring defines presence, a nursing action rooted in Watson’s caring theory. It involves empathetic engagement, active listening, and emotional availability, fostering trust and comfort for patients and families. This intentional connection supports holistic care, enhancing psychological well-being and coping during challenging moments like illness or end-of-life care.