1. A client in the critical care unit who has been oriented suddenly becomes
disoriented and fearful. Assessment of vital signs and other physical parameters
reveals no significant changes, and the nurse formulates the diagnosis of
Confusion related to ICU psychosis. Which intervention is best to implement
based on this client's behavior?:
Answer:
The best intervention is to organize care so that the client can experience rest
periods (C). The critical care unit contains many lifesaving treatment modalities
that offer clients an array of auditory, visual, and even painful stimuli. These
stressors can result in isolation and confusion. (A) is not practical because the
client may need assistance from medical equipment to survive. The client is too ill
to receive teaching (B). Although (D) may be supportive, young children are
routinely prohibited from critical care units because of increased risk of infectious
disease transmission.
2. A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia.
When the lunch tray is brought to the room, the client refuses to eat and
tells the nurse, "I know you are trying to poison me with that food." Which
response by the nurse is the most therapeutic?:
Answer:
(A) is the best choice because the nurse does not argue with the client or demand
that that the client eat but offers support by agreeing to be there if needed, which
provides an open, rather than closed, response to the client's statement. (B and C)
are challenging the client's delusions, and (B) asks "why." Probing questions,
which start with "why," are usually not therapeutic communication for a psychotic
client. (D) has not addressed the actual problem—that is, the client's delusions.
3. An adult client who lives in a residential facility is mentally retarded and
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