A Patient Experiencing Fluctuating Levels of Consciousness, Disturbed Orientation, and Perceptual

question 13

Multiple Choice

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?

• A) "There are no bugs on your legs. Your imagination is playing tricks on you."
• B) "Try to relax. The crawling sensation will go away sooner if you can relax."
• C) "Don't worry. I will have someone stay here and brush off the bugs for you."
• D) "I don't see any bugs, but I know you are frightened so I will stay with you."

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Definitions:

REM Sleep

A sleep phase characterized by rapid eye movement, during which dreaming and increased brain activity occur.

Full-Term Babies

Infants born after the normal gestation period, typically between 37 to 42 weeks, and are considered developmentally ready for life outside the womb.

Critical Attachment

Strong emotional bond that critically influences one's sense of security and relationship dynamics. (Note: The term might be an amalgamation of "critical period" and "attachment theory," but this definition integrates possible intent.)

Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS)

A comprehensive assessment tool used to evaluate the neurological functioning, behavior, and stress responses of newborns, particularly those at risk due to prematurity or other health issues.