A client is admitted to the psychiatric unit after taking various medications and illegal substances to get "high."
In addition to his underlying diagnosis of bipolar disorder, the client is diagnosed with delirium. Currently, he is experiencing mild hallucinations and confusion. Which intervention should the nurse do first?
A) Loosely apply a vest restraint
B) Obtain an order for haloperidol
C) Arrange for an unlicensed assistant to sit with the client
D) Organize diversional activities for the client.
Ans: C
Feedback:
The team must structure the client's environment to ensure safety as well as to maximize cognitive abilities and psychological comfort. Providing a private room for the client is beneficial so that staff can minimize noxious and confusing environmental stimuli and maximize the use of a sitter or supportive family members.
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