The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit?
a. Assessing the patient's level of consciousness and documenting every 4 hours
b. Keeping a day-by-day calendar at the patient's bedside and having the patient manage it
c. Placing a patient observer in the patient's room for safety
d. Informing the patient that she cannot be discharged unless she is awake, alert, and oriented
ANS: B
Keeping a calendar in the patient's room helps to orient the patient to the dates and gives the patient a sense of control over her environment. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.
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