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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is choicea. Low self-esteem,b. Family history of addiction, andd. Personality disorders.
Choice A rationale:
Low self-esteem is considered a risk factor for addictive disorders.Individuals with low self-esteem may use substances as a coping mechanism to deal with negative feelings about themselves.
Choice B rationale:
A family history of addiction is a significant risk factor.Genetic predisposition plays a crucial role in the development of addictive behaviors.
Choice C rationale:
Asian ethnicity is not typically considered an etiological factor for addictive disorders.In fact, some studies suggest that certain genetic factors in Asian populations may reduce the risk of alcohol addiction.
Choice D rationale:
Personality disorders, such as borderline personality disorder or antisocial personality disorder, are associated with a higher risk of substance use disorders.These disorders can lead to behaviors that increase the likelihood of addiction.
Choice E rationale:
Being female is not a direct etiological factor for addictive disorders.However, gender can influence the patterns and consequences of substance use, with males generally having a higher prevalence of substance use disorders.
Correct Answer is ["A","B","D","E"]
Explanation
The correct answer is Choice A, Choice B, Choice D, Choice E.
Choice A rationale: Offering specific privileges for sustained weight gain acts as positive reinforcement, motivating the client to adhere to the treatment plan. It supports behavior change and helps in gradually restoring a healthy weight, vital in anorexia nervosa management.
Choice B rationale: Monitoring the client's weight daily allows for accurate tracking of progress and ensures timely intervention if weight loss continues. It helps the healthcare team make necessary adjustments to the treatment plan to meet nutritional and therapeutic goals.
Choice C rationale: Allowing the client to choose their meals can lead to poor nutritional choices due to their distorted perception of body image and fear of gaining weight. Structured meal plans are essential to ensure balanced nutrition and recovery in anorexia nervosa.
Choice D rationale: Providing the client with small meals frequently helps in preventing overwhelming feelings during meals and reduces the risk of refeeding syndrome. This approach promotes consistent nutritional intake and supports gradual weight gain.
Choice E rationale: Staying with the client during meals and for 1 hour afterward prevents purging behaviors and provides emotional support. It also ensures the client consumes the prescribed food, facilitating adherence to the nutritional plan and promoting recovery.
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