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
Choice A Reason:
Requesting an x-ray of the preschooler's neck is not typically indicated for RSV. RSV primarily affects the respiratory system, and neck x-rays are not a standard diagnostic tool for this condition.
Choice B Reason:
Initiate droplet precautions are incorrect. This is the most appropriate action for RSV. RSV is primarily transmitted through respiratory droplets. Droplet precautions involve wearing a mask and maintaining a safe distance from the infected child to prevent the spread of the virus to others. It's a standard infection control measure for RSV.
Choice C Reason:
Monitoring the preschooler's urine for protein is not relevant to RSV. RSV primarily affects the respiratory system and does not typically cause kidney problems.
Choice D Reason:
Administering fluconazole is not indicated for RSV. Fluconazole is an antifungal medication, and RSV is a viral respiratory infection. Antifungal medications like fluconazole are not effective against viruses like RSV.
Correct Answer is D
Explanation
Choice A Reason:
Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.
Choice B Reason:
Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.
Choice C Reason:
Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.
Choice D Reason:
This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.
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