A nurse is caring for an older adult client who is postoperative.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client’s progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Delirium The client’s symptoms such as disorientation to time and place, disorganized thinking, lack of attention, rambling speech, and changes in behavior that began the prior evening suggest the client is most likely experiencing delirium12. Delirium is common in older adults who are postoperative and can be triggered by factors such as dehydration, infection, and certain medications.

Actions to Take:

Choice A: Monitor client’s fluid intake and output The client has refused to eat or drink since the previous day and has a significant difference between intake (250 mL) and output (2,500 mL), suggesting possible dehydration3. Monitoring the client’s fluid intake and output can help assess the client’s hydration status and the effectiveness of interventions such as IV fluid administration.

Choice E: Encourage family members to stay with the client Family members can provide a familiar and reassuring presence, which can help orient the client and potentially reduce agitation and restlessness. They can also provide valuable information about the client’s normal behavior and any changes they have noticed.

Parameters to Monitor:

Choice A: Fall risk The client is attempting to get out of bed without assistance, which increases the risk of falls4. Monitoring the client’s mobility and implementing fall prevention strategies is crucial.

Choice E: Sleep-wake cycle The client has been awake most of the night, indicating a disruption in the sleep-wake cycle5. Monitoring the client’s sleep patterns can provide information about the progression of delirium and the effectiveness of interventions.

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Correct Answer is C

Explanation

Choice A: Aripiprazole
Aripiprazole is an antipsychotic medication primarily used to treat conditions such as schizophrenia, bipolar disorder, and major depressive disorder. It works by helping to restore the balance of certain natural chemicals in the brain (neurotransmitters). However, it is not typically used for smoking cessation. There is no substantial evidence supporting its effectiveness in helping individuals quit smoking.

Choice B: Quetiapine
Quetiapine is another antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder. Similar to aripiprazole, it works by affecting neurotransmitters in the brain. While quetiapine can help manage symptoms of mental health disorders, it is not indicated for smoking cessation. There is no clinical evidence suggesting that quetiapine is effective in helping individuals stop smoking.

Choice C: Bupropion
Bupropion is an atypical antidepressant that is also used as a smoking cessation aid. It works by inhibiting the reuptake of norepinephrine and dopamine, which helps reduce withdrawal symptoms and the urge to smoke. Bupropion is one of the few medications approved by the FDA for smoking cessation. It has been shown to be effective in helping people quit smoking by reducing cravings and withdrawal symptoms. Therefore, it is the correct choice for a medication to include in smoking cessation information.

Choice D: Risperidone
Risperidone is an antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability associated with autistic disorder. Like aripiprazole and quetiapine, it works by affecting neurotransmitters in the brain. Risperidone is not used for smoking cessation, and there is no evidence to support its effectiveness in helping individuals quit smoking.

A. Therapeutic hold B. Restraint C. Diversion D. Time-out

Correct Answer is C

Explanation

Choice A Reason:
A therapeutic hold is a technique used to safely secure a patient during a procedure or when they are a danger to themselves or others. It is not typically considered a de-escalation technique but rather a response to escalated behavior.

Choice B Reason:
Restraint is a measure used to prevent a patient from causing harm to themselves or others. It is usually a last resort after de-escalation techniques have failed and is not a de-escalation technique itself. Restraint can sometimes escalate the situation further and should be used cautiously.

Choice C Reason:
Diversion, or distraction, is a de-escalation technique that involves redirecting the patient's attention from what is causing their agitation to something less stressful or more positive. This can help calm the patient and prevent the situation from escalating.

Choice D Reason:
Time-out is a strategy where a patient is moved to a separate room to be alone and calm down. While it can be part of a de-escalation strategy, it is not a technique that the nurse would document as having actively employed in the moment of de-escalation.

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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