Unit 19

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which?

1. Move the client next to the nurse's station. 2. Use a night light and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room. 2. Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

1. Poor dietary choices 2. Lack of exercise and poor diet 3. Inadequate dietary intake and dehydration 4. Psychomotor retardation and side effects of medication 4. Rationale: In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?

1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. 3. Offer to take the client to an examination room until he or she can be treated. 4. Inform the client that he or she will be asked to leave if the behavior continues. 3. Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be 'cured'?" 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia." 3. Rationale: Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

1. Open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition 1. Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons but should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

1. Plan short-term goals. 2. Identify expected outcomes. 3. Assist in making appropriate referrals. 4. Assist in developing realistic solutions. 3. Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.