The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion?
a. Keep a day-by-day calendar at the patient's bedside.
b. Place a patient observer in the patient's room for safety.
c. Assess the patient's level of consciousness and document every 4 hours.
d. Prepare to discharge once the patient is awake, alert, and oriented.
ANS: A
Keeping a calendar in the patient's room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.
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