Which of the following statements would be most important for the nursing staff to consider when planning delirium management for a client?
1. Provide education for family members as needed
2. Decrease all stimulation in the client's room
3. Sensory deprivation and over stimulation can worsen symptoms
4. Ask the family to involve the client in all conversations and interactions
3. Sensory deprivation and over stimulation can worsen symptoms
Rationale:
The structure of the client's environment should support cognitive functions. Aids for hearing or vision are necessary to prevent sensory loss or distortion. Familiar objects from home, such as slippers, robe, and photographs, may help with orientation. Easily read clocks, orientation boards, and a structured routine that includes physical activity and socialization without sensory overload will also help with orientation. Clients with delirium can exhibit hyperactivity when over stimulated.
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A comatose patient with a traumatic brain injury is being tested for cranial nerve damage. The nurse passes a wisp of cotton over the lower conjunctiva of each eye
The patient's lower eyelid in each eye twitches when the cotton makes contact with the cornea. The nurse recognizes that this result indicates which of the following? A) The trigeminal nerve is functioning properly but the facial nerve is not B) The facial nerve is functioning properly but the trigeminal nerve is not C) Neither the trigeminal nerve nor the facial nerve is functioning properly D) Both the trigeminal and the facial nerves are functioning properly
Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating,
"Although I'd like to, I don't join in because I don't speak the language very well." Within 1 week, the patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.
A nurse entering the job market wants to be certain that the first position is rewarding and allows for growth as a registered nurse. According to the Hallmarks of the Professional Nursing Environment, the nurse should ask:
a. about the philosophy related to clinical care to determine the role of RNs in deciding outcomes related quality outcomes. b. if professional development opportunities are supported through paid leave and tuition reimbursement. c. how compensation packages compare to others in the same area and nationally. d. what the projected need for RNs is in the next 5 years and current turnover rate.
Which of the following statements regarding isotonic crystalloid solutions is correct?
A. The ability of isotonic crystalloids to cross membranes and alter fluid levels makes them dangerous to use for fluid replacement. B. Isotonic crystalloids, such as normal saline, have the ability to carry and deliver oxygen to the body's cells. C. You should infuse 1 mL of isotonic crystalloid solution for every 3 mL of estimated blood loss. D. Approximately two thirds of infused isotonic crystalloid solution will leave the vascular space within 1 hour.