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What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
- A. Avoidance of physical contact
- B. High level of sensory stimulation
- C. Careful observation and supervision
- D. Application of wrist and ankle restraints
Correct Answer: C
Rationale: Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.
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A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, 'Someone get these bugs off me.' What is the nurse's best response?
- A. There are no bugs on your legs. Your imagination is playing tricks on you.'
- B. Try to relax. The crawling sensation will go away sooner if you can relax.'
- C. Don't worry. I will have someone stay here and brush off the bugs for you.'
- D. I don't see any bugs, but I know you are frightened so I will stay with you.'
Correct Answer: D
Rationale: When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
- A. Assist the patient to perform simple tasks by giving step-by-step directions.
- B. Reduce frustration by performing activities of daily living for the patient.
- C. Stimulate intellectual function by discussing new topics with the patient.
- D. Promote the use of the patient's sense of humor by telling jokes.
Correct Answer: A
Rationale: Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless.
Which environmental adjustment should the nurse make for a patient experiencing delirium with 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.
Correct Answer: D
Rationale: A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, 'Bugs are crawling on my legs! Get them off!' Which problem is the patient experiencing?
- A. Aphasia
- B. Dystonia
- C. Tactile hallucinations
- D. Mnemonic disturbance
Correct Answer: C
Rationale: The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
Which nursing intervention is appropriate to use for patients diagnosed with either delirium or dementia?
- A. Speak in a loud, firm voice.
- B. Touch the patient before speaking.
- C. Reintroduce the health care worker at each contact.
- D. When the patient becomes aggressive, use physical restraint instead of medication.
Correct Answer: C
Rationale: Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.