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 B
Explanation
The correct answer is choice B. "It sounds like you're having a difficult time."
Choice A rationale:
"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.
Choice B rationale:
"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.
Choice C rationale:
"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.
Choice D rationale:
"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.
Correct Answer is D
Explanation
Choice A rationale:
This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.
Choice B rationale:
This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.
Choice C rationale:
While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.
Choice D rationale:
This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.
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