When the nurse receives information that a client with delirium ...

[Caiter2013]

When the nurse receives information that a client with delirium is being admitted to the unit,
 
  the
  nurse would expect to document assessment findings that include (more than one answer may be
  correct)
  A. unimpaired level of consciousness.
  B. disorientation to place and time.
  C. wandering of attention.
  D. perceptual disturbances.
  E. self-care competence.
  F. stable autonomic signs.

Question 2

A client being treated in the burn injury unit has demonstrated good coping skills for several weeks.
  Today, a new nurse is assigned to care for him and has proven to be poorly organized.
 
  His usual
  schedule has not been followed and by midafternoon he is angry and raises his voice to complain to
  the nurse clinician. The best course of action for the nurse clinician would be to
  a. explain the reasons for the disorganization and take over his care for the rest of
  the shift.
  b. acknowledge and validate his distress and ask what he would like to have happen.
  c. apologize and explain that he will have to live with the situation for the rest of the
  shift.
  d. ask him to control his anger and tell him allowances must be made for new staff.

[Brummell1998]

Answer to Question 1

B, C, D
Rationale: Option B is an expected finding. Orientation to person (self) usually remains intact.
Option C: Attention span is short, and difficulty focusing or shifting attention as directed is often
noted. Option D: Illusions and hallucinations are commonly experienced by clients with delirium.
Option A: Fluctuating levels of consciousness are expected. Option E: Self-care deficits are usually
noted. Option F: Autonomic signs, tachycardia, seating, flushing, dilated pupils, and elevated blood
pressure are often present.

Answer to Question 2

B
When a client with good coping skills is angry and overwhelmed, the goal is to reestablish a means
of dealing with the situation. The nurse should problem solve with the client by acknowledging the
client's feelings, validating them as understandable, apologizing as necessary, then seeking an
acceptable solution. Often clients can tell the nurse what they would like to have happen as a
reasonable first step.

[Caiter2013]

TYSM

[nguyenhoanhat]

Gracias!