The nurse is caring for an older client who experienced a hip ...

[burchfield96]

The nurse is caring for an older client who experienced a hip replacement surgery 10 hours ago. Which intervention will help minimize this client's risk of developing delirium?
 
  a. Requesting that staff offer fluids each time they interact with the client
  b. Medicating the client to best facilitate re-storative sleep
  c. Encouraging the client to remain still and thus minimize pain
  d. Suggesting that visitors are limited to fam-ily members only

Question 2

A nurse in a long-term care facility is approached by an older resident who is crying and states: You need to help me. The mean little men are in my room again. They are watching me from the corner and they are laughing at me.
 
  Make them go away. The nurse accompanies the resident to the room and there is no one in the corner of the room. What is the best response by the nurse? (Select all that apply.)
  a. Yup, I see them. Let me call security to haul the men away.
  b. Can you tell me what you are so fright-ened of?
  c. I will do my best to keep you safe.
  d. I understand that you are very frightened and upset.
  e. You know that there is no one there. Stop carrying on like this.

[kusterl]

Answer to Question 1

ANS: A
Encouraging fluid intake will help prevent dehydration, which is a major contributor to the de-velopment of delirium. Avoid use of sleeping medicationsuse music, warm milk, or noncaf-feinated herbal tea to alleviate discomfort and encourage sleep. Avoid excessive bed rest; insti-tute early mobilization as appropriate. It is appropriate to have family and visitors available to the client, within reason, since doing so will help stimulate the client cognitively.

Answer to Question 2

ANS: B, C, D
When dealing with a patient with frightening delusion, the nurse needs to be understanding, but not pretend to agree with the delusions. The nurse needs to ask what is troubling to the patient and provide a reassurance of safety. It is important to try and understand the patient's level of distress and what the patient is experiencing. Option A agrees with the delusion; option E does not provide reassurance or safety.