What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Avoidance of physical contact
Application of wrist and ankle restraints
Careful observation and supervision
High level of sensory input
The Correct Answer is C
A. Avoidance of physical contact is not the priority intervention for a patient with delirium. While you may want to be gentle and avoid unnecessary contact, the priority is to ensure the patient's safety and provide support in a way that helps prevent injury, confusion, or further agitation.
B. Application of wrist and ankle restraints is not recommended unless absolutely necessary for patient safety (such as if the patient is at risk of harming themselves or others). Restraints should be a last resort and only used when all other interventions have failed.
C. Careful observation and supervision is the priority nursing intervention for a patient with delirium. Due to fluctuating levels of consciousness and altered perception, the patient is at risk for injury (e.g., falling, wandering). Close observation helps ensure the patient's safety and provides an opportunity to intervene if the condition worsens.
D. High level of sensory input is generally not recommended for patients with delirium, as it may increase confusion and agitation. Instead, providing a calm, quiet environment with minimal distractions is typically preferred.
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Related Questions
Correct Answer is C
Explanation
A. Gradual progressive onset. Dementia typically has a gradual onset and progresses over time. This is true for most types of dementia, such as Alzheimer's disease, where symptoms slowly worsen over months and years.
B. Can be classified as either primary or secondary. Dementia can be classified as primary (such as Alzheimer's disease or frontotemporal dementia, where the brain itself is primarily affected) or secondary (where dementia is caused by another condition, such as a stroke or a brain injury).
C. It does not interfere with navigation of daily life. This statement is incorrect. One of the defining features of dementia is that it does interfere with daily life. As cognitive functions decline, individuals often have difficulty with tasks such as managing finances, cooking, driving, and maintaining personal hygiene.
D. It is irreversible. While some types of dementia (like Alzheimer's disease) are irreversible and progressive, there are certain conditions, like some forms of vascular dementia, where the progression can be slowed or stabilized if the underlying cause is addressed. However, many forms of dementia are indeed irreversible.
Correct Answer is C
Explanation
A. "I have been depressed for a long time" is a statement that reflects personal feelings but does not specifically demonstrate a common response from perpetrators of violent sexual assault. While depression can affect anyone, it is not directly related to the perpetrator's denial or justification for the crime.
B. "She dressed provocatively" is a common victim-blaming tactic used by some perpetrators to justify their behavior, but it still focuses on the victim’s actions rather than taking responsibility. It may reflect the perpetrator's need to rationalize their actions, but it is not as explicit in denying responsibility as statement C.
C. "It is not my fault she was asking for it" is the most likely statement from a perpetrator of sexual assault, as it directly reflects blame-shifting and a lack of accountability for the assault. This type of statement is commonly used by individuals attempting to justify their actions by suggesting that the victim provoked or deserved the assault, a typical defense mechanism in cases of sexual violence.
D. "Was under the influence of alcohol" is also a common defense used by perpetrators to attempt to excuse their actions by claiming they were impaired. While alcohol use is often involved in assaults, it does not carry the same blame-shifting implication as statement C.
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