A newly admitted patient is mute, immobile, and holds a fixed body position for long periods. The nurse caring for this patient should
a. assign unlicensed assistance personnel to feed the patient.
b. provide a stimulating, active environment.
c. encourage independent social behaviors.
d. forewarn the patient before touching.
D
Nurses should explain the need for and purpose of touch to patients before actually touching. This is particularly true for patients who are at highest risk for misinterpreting touch: those who are inattentive to reality or those who are suspicious. The environment should be calm and predictable. A patient who is mute and motionless is incapable of independent social behaviors. The patient's oral intake should be monitored, but the correct response also applies to feeding, if it is necessary.
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