A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?
Determine the client's level of consciousness
Administer an anxiolytic medication.
Keep lights on in the client's room.
Encourage visits from family members.
The Correct Answer is A
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Correct Answer is D
Explanation
Choice A Reason:
Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.
Choice B Reason:
Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.
Choice C Reason:
When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).
Choice D Reason:
Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance.CPM is typically initiatedearly postoperatively, often within the first 24 hours after surgery.
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