The nurse is continuing to assist in the care of the client. Exhibits Which of the following actions should the nurse take? Select all that apply.
Explanation & Rationale
Rationale: • Write the full date on the client's whiteboard: Writing the date helps reinforce orientation to time, which the client is lacking. Visual cues are essential for reorienting clients with delirium. This simple step can reduce confusion and distress. • Acknowledge the client's feelings: Acknowledging the client’s fear builds trust and therapeutic rapport. It reduces agitation and reassures the client when they experience hallucinations. Validation helps calm the client without reinforcing delusions. • Request that the client's family bring the client's eyeglasses from home: Requesting the glasses improves the client’s ability to recognize surroundings. Visual impairment worsens confusion in older adults. Familiar visual aids reduce cognitive strain. • Request that the client have the same caregivers with every shift: Consistent caregivers help the client form familiar relationships. Continuity reduces confusion, especially in clients with dementia or delirium. Routine and predictability lower anxiety. • Reorient the client often: Frequent reorientation is key in delirium management. It helps the client regain understanding of time, place, and situation. Repetition promotes memory and reduces disorganized thoughts. • Ask the client's partner to stay with the client as much as possible: The partner provides emotional comfort and familiarity. Their presence helps maintain the client’s orientation and decreases agitation. Family members often support communication and reorientation. • Provide the client with information about what to expect during their care: Detailed information may overwhelm or confuse a delirious client. Cognitive overload can worsen disorientation. Simpler, brief explanations are more effective. • Maintain a well-lit environment: Bright lighting may worsen hallucinations or cause overstimulation. Soft, ambient lighting is better suited for reducing visual misperceptions. Delirious patients benefit from calm, low-stimulation environments.