An older client has become very confused since being hospitalized ...

[B]

An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?
 
  1. As reversible confusion
  2. As sundown syndrome
  3. As delirium
  4. As dementia

Question 2

A client who has had a traumatic brain injury is physiologically stable but remains in a coma. Caregivers are participating in a coma stimulation program with this client. Which action is correct for this situation?
 
  1. Provide visual and tactile stimulation concurrently with auditory background.
  2. Limit stimulation to a 5- to 10-minute session.
  3. Provide continuous auditory stimulation through music tapes.
  4. Ensure the client has sleep/rest periods alternating with sensory stimulation.

[Ksanderson1296]

Answer to Question 1

Correct Answer: 3
Rationale 1: The nurse has no way of knowing if this client's confusion is reversible.
Rationale 2: There is not enough information to determine if the client is experiencing sundown syndrome.
Rationale 3: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client.
Rationale 4: Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible.

Answer to Question 2

Correct Answer: 4
Rationale: These coma stimulation programs are a means of providing sensory stimulation to promote brain recovery. Stimulation should be delivered in a quiet environment, should be limited to 30- to 45-minute sessions, and should be done episodically throughout the day, not continuously. Periods of sleep/rest should be alternated with the sensory stimuli.

[B]

Excellent

[dantucker]

TYSM