NCLEX PREP: SATA QUESTIONS & PSYCH

Summary

This video script covers two clinical scenarios in nursing care. The first involves managing confusion in a client with cerebral arterial sclerosis, focusing on strategies like limiting choices, accepting the client as they are, and explaining tasks step by step. The second scenario addresses delirium following a myocardial infarction, emphasizing the importance of reducing stimuli, avoiding challenging hallucinations, and gently presenting reality. Both cases highlight key nursing interventions aimed at maintaining safety and comfort, while acknowledging the client’s cognitive challenges in acute conditions.

Takeaways

• 😀 Limit the client's choices to reduce confusion, as offering too many options can overwhelm them.
• 😀 Accepting the client as they are is essential in fostering a therapeutic and supportive environment, especially when they are confused.
• 😀 Explaining tasks step-by-step helps confused patients understand and follow instructions more effectively.
• 😀 Allowing a confused client to do whatever they wish can lead to unsafe behaviors, like pulling out medical devices.
• 😀 Acting nonchalantly in response to a patient's confusion is inappropriate and may worsen agitation or distress.
• 😀 Delirium is an acute, reversible condition, often caused by illness or medication, and requires immediate intervention to ensure safety.
• 😀 Dementia is a chronic, progressive condition that does not cause sudden onset confusion like delirium does.
• 😀 Reducing environmental stimuli (such as noise or light) can help soothe a delirious patient and prevent further agitation.
• 😀 Avoid challenging the client's delusions or hallucinations; instead, focus on providing comfort and reassurance.
• 😀 Gently presenting reality, when needed, can be helpful in delirium, but it should be done with a light touch to avoid confrontation.
• 😀 Orienting a delirious patient about their medical condition is not advisable, as they are unable to process complex information during an episode of delirium.

Q & A

What is the likely cause of the client's confusion in the first scenario?

The client’s confusion is attributed to cerebral arterial sclerosis, which is likely a form of dementia, as the confusion is increasing over time and has a physiological basis.

What is the primary goal of nursing staff in managing a confused client with cerebral arterial sclerosis?

The primary goal is to prevent the client from becoming agitated or frustrated, as these emotional responses can exacerbate the confusion and worsen the client's condition.

Why is limiting the client's choices considered a good approach in managing confusion?

Limiting choices helps to reduce cognitive overload, making decision-making easier for confused clients. Offering fewer options prevents them from becoming overwhelmed and forgetting earlier options.

What does 'accepting the client as they are' mean in the context of managing confusion?

Accepting the client as they are involves offering nonjudgmental care, acknowledging their confusion without pushing them to meet specific expectations. This therapeutic approach helps build trust and reduces frustration.

Why is it not advisable to allow the client to do as they wish when they are confused?

Allowing the client to do as they wish can lead to unsafe behaviors, such as pulling out IVs or engaging in inappropriate actions, which may harm them or disrupt their care.

What does acting nonchalantly toward a confused client imply, and why is it not recommended?

Acting nonchalantly implies a lack of concern or attention, which could be perceived as uncaring. This approach does not support therapeutic communication and is generally unhelpful in managing confusion.

Why is it important to explain tasks step by step to a confused client?

Confused clients may struggle to remember or follow multi-step instructions. Breaking tasks into smaller, manageable steps helps ensure they can follow through and reduces the risk of further confusion.

What key symptoms suggest that the client in the ICU is experiencing delirium rather than dementia?

Delirium is characterized by acute, fluctuating confusion, hallucinations, and changes in consciousness, as seen in the ICU client. The client’s condition developed suddenly after an MI (myocardial infarction), which is typical of delirium rather than the gradual onset seen with dementia.

What is the most appropriate action when managing a client who is experiencing delirium and hallucinating (e.g., 'baby angels')?

The best approach is to avoid challenging the client's perceptions. Since delirium involves altered reality, challenging hallucinations could cause distress and increase confusion. It is more effective to accept the client’s experience and ensure their safety.

Why is it not appropriate to orient the client to their medical condition during an episode of delirium?

During delirium, the client is not in a cognitive state to comprehend complex information about their medical condition. Orienting them to such information would likely increase confusion and frustration, as they are unable to process it effectively.

What does 'gently presenting reality as needed' mean in the context of delirium, and why is it a useful approach?

Gently presenting reality means providing subtle, non-confrontational reminders of the truth when necessary. This is a gentle form of reality orientation that can help reassure the client without overwhelming them, avoiding the harsh confrontation typical in more rigid approaches.