A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
A client with a history of confusion 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?”
[7%]
B. “Hello, my name is Susan Jones and I am your nurse for today.”
[12%]
C. “How are you today? Remember, you’re in the hospital.”
[1%]
D. “Good morning. You’re in the hospital. I am your nurse, Susan Jones.”
[80%]
Statistics
Subject/Lesson
Subject
Fundamentals
Lesson
Basic Care & Comfort
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Therapeutic Communication
Item Type
Item Type
Application
Explanation
Choice D is correct. This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, the nurse needs to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion.
Choices A and C are incorrect. The patient is confused and most likely does not know where he is. Asking him what he remembers may cause increased anxiety. Instead, the nurse should explain where the patient is and why to help ease his frustration.
Choice B is incorrect. Although introducing yourself is essential, the client needs more information than merely the nurse’s name.
NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Interventions for Confused Clients
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2 Key Topics
Cognitively Impaired
