hard · NCLEX-RN basic-care
A 68-year-old client with end-stage metastatic renal cell carcinoma is transitioning in an inpatient hospice facility. The client is experiencing acute hyperactive delirium, characterized by picking at the air, attempting to climb out of bed, and shouting at unseen visitors. Which interventions should the nurse include in the client's care plan? Select all that apply.
- Apply four-point soft wrist and ankle restraints to prevent falls.
- Minimize ambient noise, dim the lights, and limit the number of visitors at the bedside.
- Initiate hourly neurological assessments, including pupil size and reflex checks.
- Perform a forceful confrontation to correct the client's visual hallucinations.
- Provide gentle, brief verbal reorientation and have a familiar caregiver remain at the bedside.
- Administer prescribed low-dose haloperidol or chlorpromazine.
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