You are the hospice nurse caring for a 45-year-old mother of three young children in her home
When you make your visit, you discover that your patient has an altered mental status. Your assessment indicates the patient is delirious. What would your nursing interventions be aimed at?
A) Helping the family to understand why the patient needed to be sedated
B) Making arrangements to move the patient to an acute-care facility
C) Explaining to the family that death is near and the patient needs around-the-clock nursing care
D) Teaching family members how to interact with and ensure safety for the patient with delirium
Ans: D
Feedback: Nursing interventions are aimed at identifying the underlying causes of delirium; acknowledging the family's distress over its occurrence; reassuring family members about what is normal; teaching family members how to interact with and ensure safety for the patient with delirium; and monitoring the effects of medications used to treat severe agitation, paranoia, and fear. Options A, B, and C are incorrect; the scenario does not indicate the need to either sedate the patient or move her to an acute-care facility. If the family has the resources, there is no need to bring in nurses to be with the patient around-the-clock, and the scenario does not indicate that death is imminent.
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