A nurse is caring for a 65-year-old male client in the emergency department (ED). Exhibits Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.
Explanation & Rationale
Choice A rationale: Maintaining a low stimulation environment helps reduce agitation and confusion in clients with delirium. Minimizing noise, light, and activity can create a calming atmosphere, which is essential for clients experiencing sensory overload and cognitive disturbances. Choice B rationale: Alternating nursing staff daily can disrupt continuity of care, which may increase the client's confusion and anxiety. Familiarity with consistent caregivers helps provide a stable environment, promoting better management of delirium symptoms. Choice C rationale: Providing the client with limited information about their diagnosis is not helpful. It is important to keep the client informed to the extent they can understand, which helps in reorienting them and reducing confusion about their situation. Choice D rationale: Approaching the client slowly is crucial in managing agitation and confusion. A calm and non-threatening approach helps in gaining the client's trust, making them feel more secure and reducing the likelihood of aggressive behavior. Choice E rationale: Reorienting the client to person, place, and time frequently is vital in managing delirium. Regular reorientation helps the client regain a sense of reality and reduces confusion. This intervention is key to improving cognitive function and managing disorientation.