A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?
Medicate the client with alprazolam.
Reorient the client to his surroundings.
Measure the client's vital signs.
Offer reassurance to the family.
The Correct Answer is C
Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.
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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Completing an incident report is inappropriate. While completing an incident report is important for documenting any errors or deviations from the standard of care, it should not be the first action taken. Assessing the client's condition takes precedence to ensure their immediate safety and well-being.
Choice B Reason:
Notifying the provider is inappropriate. Notifying the provider may be necessary, but it should not be the first action taken. Initially, the nurse should assess the client's condition to determine if any adverse effects have occurred as a result of the additional medication dose.
Choice C Reason:
Informing the nursing supervisor is inappropriate. Informing the nursing supervisor may be appropriate, especially if further actions or investigations are needed. However, the immediate priority is to assess the client's condition to ensure their safety.
Choice D Reason:
Observing the client's condition is appropriate. The nurse should first assess the client's condition to determine if any adverse effects have occurred due to the additional medication dose. This assessment helps identify any immediate concerns that require intervention. Based on the client's condition, further actions such as notifying the provider or completing an incident report may be warranted. However, observing the client's condition is the initial and most immediate action to take.
Correct Answer is A
Explanation
Choice A Reason:
This statement indicates an understanding of the legal and procedural aspect of using restraints. Restraints should only be applied based on a valid prescription from a healthcare provider. The phrase "as needed" implies that restraints should be used judiciously and based on the client's specific condition and behavior. It aligns with the principle that restraints should not be used unnecessarily and should be discontinued as soon as they are no longer needed to ensure the client's safety and well-being.
Choice B Reason:
This statement is incorrect regarding the use of restraints. Restraints should not be tied using a square knot because it can be difficult to untie quickly in case of an emergency or if the client needs to be released from the restraints promptly. Instead, quick-release knots should be used to ensure rapid removal of restraints when necessary.
Choice C Reason:
This statement is also incorrect regarding the use of restraints. Restraints should never be tied to a part of the bed frame that moves, such as the bed rails. Tying restraints to a moving part can lead to serious injuries if the bed is adjusted, as it can create tension or cause the client to become trapped or entangled. Restraints should be secured to a stable part of the bed frame to ensure the client's safety.
Choice D Reason:
This statement is incorrect because the timing for removing restraints should not be based on a fixed time interval like every 4 hours. Instead, the decision to remove restraints should be based on the healthcare provider's orders and the client's condition. Restraints should be removed as soon as they are no longer necessary to ensure the client's comfort, mobility, and safety. Regular assessments should be conducted to determine if restraints can be safely discontinued or if they need to be maintained based on the client's clinical status.
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