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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.
Choice B Reason:
Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.
Choice C Reason:
Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.
Choice D Reason:
Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.
Correct Answer is ["C","E","F"]
Explanation
In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.
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