A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Administer medication to sedate the client.

Call the family and ask them to stay with the client.

Apply wrist and leg restraints to the client.

Move the client to a room closer to the nurses' station.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

Lithium is a mood stabilizer commonly used to treat bipolar disorder. It helps to regulate mood swings, prevent manic episodes, and reduce the risk of depressive episodes.

Choice B rationale:

Donepezil is not used to treat bipolar disorder. It is an acetylcholinesterase inhibitor primarily used to treat symptoms of Alzheimer's disease.

Choice C rationale:

Valproate (Depakote) is another mood stabilizer used in the treatment of bipolar disorder. It can help manage both manic and depressive episodes, as well as prevent future mood swings.

Choice D rationale:

Carbamazepine (Tegretol) is an anticonvulsant medication that also has mood-stabilizing properties. It is often prescribed for individuals with bipolar disorder, especially those who do not respond well to lithium.

Choice E rationale:

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. It is not a primary medication choice for bipolar disorder.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that the client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.

Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.

Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.

Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.

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A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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