A nurse is admitting an older adult from Mumbai, India who is visiting family members in the US. Which of the following would be most appropriate for the nurse to say?

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.