An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed
She admits to being very frightened. She is presently pacing and somewhat agitated in the ex-amining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
1. Interact with the client on an adult to child level.
2. Place the client in a safe, nonstimulating environment.
3. Ask client why she thinks someone would be trying to frighten her.
4. Explain to the family that the client will be restrained for her own good.
ANS: 2
The safety of a client with delirium is of primary importance. Symptoms of delirium fluctuate and may worsen, especially at night. The greater the client's confusion and disorientation, the greater the possibility for self-harm. Option 1 is demeaning. Option 3 is inappropriate, because delirious clients cannot formulate rational answers. Option 4 is inappropriate. Clients are never restrained unless less restrictive measures have failed.
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