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Author Question: What is the priority intervention for a patient with delirium who has fluctuating levels of ... (Read 48 times)

neverstopbelieb

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on: Jul 19, 2018
What is the priority intervention for a patient with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
 
  a. Avoidance of physical contact
  b. High level of sensory stimulation
  c. Careful observation and supervision
  d. Application of wrist and ankle restraints

Question 2

Which environmental adjustment should the nurse make for a patient with delirium and perceptual alterations?
 
  a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on.
  b. Light the room brightly day and night. Awaken the patient hourly to assess mental status.
  c. Maintain soft lighting day and night. Keep a radio on low volume continuously.
  d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.


heinisk01

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Reply #1 on: Jul 19, 2018
Answer to Question 1

ANS: C
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.

Answer to Question 2

ANS: D
A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.


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