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 C

Explanation

Choice A rationale:

Ingesting lithium (Eskalith) on an empty stomach can lead to gastrointestinal upset. Therefore, clients are generally advised to take this medication with food or milk to minimize these side effects. This choice is incorrect.

Choice B rationale:

While sodium intake can impact lithium levels, clients are usually advised to maintain a consistent, moderate sodium intake rather than adopting a low-salt diet. Extreme dietary changes can affect lithium levels and potentially lead to toxicity, making this choice inaccurate.

Choice C rationale:

Monitoring blood levels of lithium is crucial to ensure therapeutic effectiveness and prevent toxicity. During the initiation phase, frequent monitoring, typically weekly, is necessary to establish the appropriate dosage for each individual. Lithium has a narrow therapeutic range, and blood levels need to be closely regulated.

Choice D rationale:

Discontinuing lithium abruptly can lead to worsened bipolar symptoms. Diarrhea can contribute to dehydration and electrolyte imbalances, potentially impacting lithium levels, but stopping the medication is not the initial action to take. Adjustments in dosage or management strategies are usually explored before considering discontinuation.

A. A room without a window. B. A room containing personal belongings. C. A room adjacent to the nursing station. D. A room with dim lighting.

Correct Answer is B

Explanation

The correct answer is choice B. A room containing personal belongings.

Choice A rationale:

Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.

Choice B rationale:

A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.

Choice C rationale:

Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.

Choice D rationale:

Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.

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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

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

Correct Answer is B

Explanation

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