Which environmental adjustment should the nurse make for a patient with delirium and perceptual alterations?
a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on.
b. Light the room brightly day and night. Awaken the patient hourly to assess mental status.
c. Maintain soft lighting day and night. Keep a radio on low volume continuously.
d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
ANS: D
A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
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It has been proposed that a new, better approach to health care be tested with a small group to evaluate its effectiveness. Which of the following best describes why this cannot be done?
a. Any employment in the project would be only temporary, so it would be difficult to find professionals to staff the program. b. It is challenging to find appropriate sites located in the target area from which to offer the pilot project service. c. No one wants to accept free services if they include being a guinea pig in a research project. d. Offering a service establishes a precedent and a sense of entitlement, so it is difficult to discontinue the program.
The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which of the following descriptions would best support this finding?
1. Yellow without sediment 2. Blood-tinged without sediment 3. Clear, colorless 4. Pink without sediment
A client in the healthcare facility asks the nurse what immediate action is taken in case of a fire. Which should the nurse inform the client?
A) Call "Code Pink." B) Rescue the client to safety. C) Inform the disaster medical assistance team. D) Use a fire extinguisher.
The patient is legally blind in both eyes. Which of the following statements is most appropriate for the nurse to make to the patient regarding providing the patient with assistance?
a. "I will walk in front of you, and you can hold onto my belt." b. "I know that you must need me to be your sighted guide to get around in this facility." c. "I will warn you of upcoming curbs or stairs." d. "I will get you a wheelchair so that I can move you around safely."