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    Ati pn comprehensive predictor 2023 proctored exam
    Select All That Apply

    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.

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