The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client?

Select all that apply.
  • maintain normal toileting routines
  • minimize visitation so that the client may rest
  • evaluate the client’s medications for side effects
  • keep familiar items such as family pictures near the bedside
  • use calendars and clocks to orient the client to the date and time
  • place the client in a room near the end of the hall to minimize noise
Numbers 1, 3, 4, and 5 are correct.
Maintaining normal toileting routines and frequent checks for toileting needs helps reassure the client that her needs are being met. Many medications cause further confusion, so the nurse should note any medications that might need to be reviewed with the health care provider. Having pictures and other familiar objects reinforces that the room belongs to the client during her stay. Clocks and calendars help orient the client and give her a sense of time and place. Family members and visitors should be encouraged, not discouraged, to visit as they can help alert the nurse to client needs. Companionship is important to the client’s self-esteem and may prevent boredom, which can lead to getting up unassisted or wandering. The client should be as close to the nurses’ station as possible so that frequent checks by multiple staff are quicker and easier.