A patient diagnosed with delirium has become agitated and fearful. Which nursing inter-vention should the nurse implement to help prevent a catastrophic response?
a. Interact with the patient on an adult-to-child level.
b. Place the patient in a safe, nonstimulating environment.
c. Ask the patient to explain what is causing the agitation and fear.
d. Be prepared to apply physical restraints to minimize the patient's risk for injury.
ANS: B
The safety of a patient with delirium is of primary importance. Symptoms of delirium fluctu-ate and may worsen, especially at night. The greater the patient's confusion and disorienta-tion, the greater the possibility for self-harm. The patient should be treated as an adult; to do otherwise is demeaning. Asking for an explanation is inappropriate, because delirious patients cannot formulate rational answers. Patients are never restrained unless all other less restrictive measures have failed.
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