Asked by Tiffiny arnold on May 18, 2024

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What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?

A) Avoidance of physical contact
B) High level of sensory stimulation
C) Careful observation and supervision
D) Application of wrist and ankle restraints

Fluctuating Levels

Variations in the intensity or quantity of something over a period of time, often applied to mood, hormones, or natural phenomena.

Orientation

The process of learning or adapting to a new environment, situation, or set of rules.

Perceptual Alterations

Changes in the way an individual perceives reality, which may involve hallucinations or altered sensory experiences.

  • Use effective communication procedures with patients presenting with dementia or delirium.
  • Establish protective measures for patients undergoing varying degrees of consciousness and alterations in their perception.
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MT
Miriam TreviñoMay 19, 2024
Final Answer :
C
Explanation :
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.