What is the best initial nursing intervention?
A male client with delirium becomes disoriented and confused in his room at night.
A. Move the client next to the nurse s station. B. Use an indirect light source and turn off the television. C. Keep the television and a soft light on during the night. D. Play soft music during the night, and maintain a well-lit room.
Use an indirect light source and turn off the television.
Provision of a consistent daily routine and a low stimulating environment is important when the client is disorientated. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses station is not the initial action.
Test-Taking Strategy: Use the process of elimination and note the strategic word initial in the question. Eliminate options 3 and 4 first because they are comparative or alike. Focusing on the strategic word will direct you easily to option 2. Review measures related to the client who is disoriented and confused if you had difficulty with this question.