Fundamentals of Nursing Q 335
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
A. “Good morning. Do you remember where you are?”
B. “Hello. My name is Elaine Jones and I am your nurse for today.”
C. “How are you today? Remember, you’re in the hospital.”
D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
Correct Answer: D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location, and the caregiver’s name. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
Option A: Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli. Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient.
Option B: Give simple directions. Allow sufficient time for the patient to respond, to communicate, to make decisions. This communication method can reduce anxiety experienced in a strange environment.
Option C: Offer reassurance to the patient and use therapeutic communication at frequent intervals. Patient reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety.