Which intervention may help create a calm and safe environment for the patient with delirium?

Choice A reason: A bowel program prevents fecal impaction, a common trigger of autonomic dysreflexia in T4 paraplegia patients. This aligns with spinal cord injury care protocols, making it the correct nursing action to include in the home health plan to prevent this hypertensive emergency.

Choice B reason: A high-protein diet supports nutrition but doesn’t directly prevent autonomic dysreflexia, triggered by stimuli like impaction. A bowel program is more relevant, making this incorrect, as it doesn’t address the primary cause of dysreflexia in the patient’s care plan.

Choice C reason: Quad coughing aids respiratory function but is unrelated to preventing autonomic dysreflexia, caused by visceral stimuli. A bowel program targets this risk, making this incorrect, as it doesn’t address the triggers of dysreflexia in the T4 paraplegia patient’s plan.

Choice D reason: Discussing sexuality and fertility supports quality of life but doesn’t prevent autonomic dysreflexia, linked to physical triggers. A bowel program is preventive, making this incorrect, as it’s unrelated to the physiological causes of dysreflexia in the home health care plan.

Choice A reason: Four-point restraints increase agitation and risk injury in delirious patients, worsening confusion. Family presence calms and reorients, making this harmful and incorrect compared to the nurse’s goal of creating a safe, calming environment for the patient with delirium.

Choice B reason: Encouraging family members to stay provides familiarity and reassurance, reducing agitation in delirious patients. This aligns with delirium management guidelines, making it the correct intervention to create a calm and safe environment for the patient experiencing delirium in the hospital.

Choice C reason: A dark, quiet room may disorient delirious patients further, increasing confusion. Family presence offers comfort, making this counterproductive and incorrect compared to the nurse’s aim of fostering a supportive, orienting environment for the patient with delirium.

Choice D reason: High-dose sedatives risk oversedation and worsen delirium, not calming the patient safely. Family presence supports orientation, making this risky and incorrect compared to the nurse’s focus on non-pharmacological interventions to create a safe environment for the delirious patient.