Question

an older male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the clients problem as confusion related to icu psychosis. which intervention is most important for the nurse to implement?

move all machines away from the clients immediate area.
attempt to allay the clients fears by explaining the etiology of confusion.
cluster care so brief periods of rest can be scheduled during the day.
extend visitation times for family and friends.

Explanation:

Analyze the clinical scenario

An older male client in the ICU suddenly becomes disoriented and fearful. Vital signs and physical parameters are unchanged, and the problem is identified as confusion related to ICU psychosis (delirium).

Evaluate the intervention options

• Move all machines away: Infeasible in an intensive care unit where monitoring and life-support equipment are necessary.
• Explain the etiology of confusion: A disoriented and fearful client cannot process complex clinical explanations of etiology.
• Cluster care: ICU psychosis is heavily driven by sensory overload, sleep deprivation, and frequent disruptions. Clustering care to allow uninterrupted rest periods directly addresses the underlying cause of sleep deprivation and sensory overload.
• Extend visitation times: While family presence can help reorient a client, extending visitation indefinitely does not address the primary need for structured rest and reduction of sensory overload in a highly active ICU environment.

Determine the priority intervention

Clustering care to schedule brief, uninterrupted periods of rest during the day is the most effective and important nursing intervention to manage and prevent the worsening of ICU psychosis.

Answer:

• Move all machines away from the client's immediate area.
• Attempt to allay the client's fears by explaining the etiology of confusion.
• Cluster care so brief periods of rest can be scheduled during the day. (Correct answer)
• Extend visitation times for family and friends.