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    ATI PN Mental Health Proctored Exam 2023 II

    A nurse is contributing to the plan of care for a client who has acute delirium.Which of the following interventions should the nurse include in the plan of care?

    Explanation & Rationale

    Choice A rationaleKeeping the client's room dark at night can worsen delirium by reducing environmental cues and potentially increasing disorientation and fear. Clients with delirium benefit from a well-lit environment that helps them maintain a sense of reality and reduces the risk of misinterpreting stimuli.Choice B rationaleLimiting the client's need to make decisions can decrease their sense of control and autonomy, potentially increasing agitation and frustration associated with delirium. While simplifying choices is helpful, completely eliminating decision-making can be counterproductive to their engagement and orientation.Choice C rationaleDiscouraging visitation from the client's family can increase the client's feelings of isolation and anxiety, which can exacerbate delirium. Familiar faces and voices can provide comfort and reassurance, aiding in orientation and reducing agitation.Choice D rationaleProviding a consistent daily routine helps to orient the client with acute delirium to time and place, reducing confusion and anxiety. Predictable patterns of activity, such as meals, hygiene, and rest, offer structure and familiarity, which can stabilize cognitive function and promote a sense of security.

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