BHU NO - 2015
Medical & Surgical Nursing
Medium
All of the following are true about nursing care for a patient with delirium, except?
Appeared in: BHU NO - 2015
Explanation
- The statement 'Refrain family member to stay with the patient' is an incorrect nursing action for managing delirium.
- Family presence is a key therapeutic intervention. Family members provide comfort, help with reorientation, and can reduce agitation and anxiety.
- Evidence-based guidelines, such as the ABCDEF bundle for ICU care, explicitly include 'F' for Family engagement and empowerment.
- Restricting family visitation is counterproductive and can exacerbate the patient's confusion and distress.
Why Other Options Were Wrong
- Option A: This is a correct intervention. Allowing a patient to wear their own clothes helps maintain their sense of identity and personal dignity, which can be grounding for a confused individual.
- Option B: This is a correct intervention. Maintaining a consistent and familiar environment by avoiding room changes helps reduce confusion and anxiety, especially during the night when delirium can worsen (sundowning).
- Option D: This is a correct intervention. Physical restraints are associated with increased agitation, risk of injury, and worsening of psychotic symptoms. They should be avoided and used only as a last resort when there is an immediate risk of harm.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Non-pharmacological nursing interventions for delirium management to guide bedside assessment, documentation, and the next nursing action.
- A nurse's primary role in delirium management is to identify and treat underlying causes while providing a safe and supportive environment.
- Family-centered care is not just a 'nice-to-have'; it is a therapeutic intervention that improves outcomes in delirious patients. Nurses should proactively facilitate family presence.
- What if? If a family member's presence was causing increased agitation in the patient, the nurse's action would be to first assess the interaction, provide education to the family on calming techniques, and suggest short, frequent visits rather than an outright ban.
How to Approach the Question
- First, identify the question type. This is a negative-framed question using the word 'except'. This means you are looking for the one option that is FALSE or incorrect.
- Read the stem carefully to understand the core topic: 'nursing care for a patient with delirium'.
- Evaluate each option individually, asking yourself: 'Is this a TRUE and appropriate nursing action for a patient with delirium?'
- Option A (own clothes), B (avoid room changes), and D (avoid restraints) are all well-known, standard interventions to promote orientation and safety.
- Option C (refrain family) stands out as contrary to the principles of patient-centered care and reorientation.
- The option that is inconsistent with best practices is the correct answer to an 'except' question.
Concept Tested & Keywords
- Concept Tested: Non-pharmacological nursing interventions for delirium management.
- Stem keywords: nursing care, patient with delirium
- Lead-in keywords: All of the following are true, except
- Negative lead-in flag: except
Question ID
Q3MACOJwgdtLq7msi5WW--
Reference Book
E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) pp. 13837-13839, 13839-13841
E6 Nursing Fundamentals Taylor p. 273-275
Practise the full BHU NO - 2015
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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