Comprehensive exams for Mental Health Q 137
Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
Correct Answer: B. The client will maintain safety.
Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial wellbeing would be implemented. Remove all potentially dangerous objects from the client’s environment; in a disoriented, confused state, clients may use objects to harm self or others.
Option A: This client would not be able to complete activities of daily living, and safety is a priority over these tasks. Provide an appropriate environment. Maintain a low level of stimuli in the client’s environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
Option C: Interrupt periods of unreality and reorient; client safety is jeopardized during periods of disorientation; correcting misinterpretations of reality enhances client’s feelings of self-worth and personal dignity. Stay calm and reassure the patient. Maintain a calm manner with the client; attempt to prevent frightening the client unnecessarily; Provide continual reassurance and support.
Option D: The goals of remaining oriented and understanding communication would be appropriate only after the client’s acute confusion has resolved. Assess the level of anxiety. Assess the client’s level of anxiety and behaviors that indicate the anxiety is increasing; recognizing these behaviors, the nurse may be able to intervene before violence occurs.