Psychosocial Integrity Q 5
The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
A. "You know you had breakfast 30 minutes ago."
B. "I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse."
C. "I’ll get you some juice and toast. Would you like something else?"
D. "You will have to wait a while; lunch will be here in a little while."
Correct Answer: C. “I’ll get you some juice and toast. Would you like something else?”
The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Avoid challenging illogical thinking. Challenges to the patient’s thinking can be perceived as threatening and result in a defensive reaction. Maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucose levels, blood pressure.
Option A: Orient patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures a greater degree of safety for the patient.
Option B: This statement is validating the delusion. Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings). The confused patient may not completely understand what is happening. The presence of family and significant others may enhance the patient’s level of comfort.
Option D: Communicate patient’s status, cognition, and behavioral manifestations to all necessary providers. Recognize that a patient’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as a patient preference for caregivers.