A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Apply soft restraints to wrists and chest.

Administer antipsychotic medications as prescribed.

Administer sedative medications as prescribed.

Arrange for one-on-one observation for the client.

Answer and Explanation

The Correct Answer is D

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.

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Correct Answer is C

Explanation

A. Consume foods high in potassium: Potassium deficiency can contribute to certain health issues, but it is not directly linked to hearing loss. However, maintaining a balanced diet rich in nutrients, including potassium, is important for overall health.

B. Increase oral intake of water: Hydration is essential for overall health, but increasing oral intake of water is not specifically associated with decreasing the risk of hearing loss. While staying hydrated is beneficial for various bodily functions, including maintaining proper ear function, it is not a direct preventive measure for hearing loss.

C. Avoid smoking tobacco products: Smoking tobacco products is a significant risk factor for developing hearing loss. Smoking can damage blood vessels and reduce blood flow to the inner ear, leading to hearing impairment. Therefore, advising clients to avoid smoking or quit smoking is an important lifestyle modification to decrease the risk of hearing loss.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can have detrimental effects on hearing health, including increasing the risk of hearing loss and vestibular dysfunction. Therefore, limiting alcohol intake is recommended to reduce the risk of developing hearing-related problems.

A. "Your heart condition is caused by excessive stretching of the ventricles." B. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty:' C. "Your heart condition is caused from stiffening of the walls of the ventricles." D. "Your heart condition is caused by thickening of the ventricular walls and septum."

Correct Answer is A

Explanation

A. "Your heart condition is caused by excessive stretching of the ventricles": Dilated cardiomyopathy (DCM) is characterized by the dilation or enlargement of the heart's chambers, particularly the ventricles. This dilation results in weakened myocardial contraction and impaired systolic function. The primary cause of DCM is often idiopathic (unknown), but it can also be secondary to various factors such as genetics, infections, toxins, or systemic diseases. The statement correctly identifies the pathophysiological basis of DCM as excessive stretching or dilation of the ventricles, leading to impaired cardiac function.

B. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement is incorrect. Fibrous and fatty changes in ventricular tissue are characteristic of another type of cardiomyopathy known as hypertrophic cardiomyopathy (HCM), not dilated cardiomyopathy (DCM). In DCM, the primary abnormality is dilation of the heart chambers rather than fibrous and fatty changes in the myocardium.

C. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement describes restrictive cardiomyopathy (RCM), not dilated cardiomyopathy (DCM). In restrictive cardiomyopathy, the ventricular walls become stiff and rigid, impairing diastolic filling and ventricular relaxation. However, in DCM, the primary abnormality is dilation or enlargement of the ventricles rather than stiffening of the ventricular walls.

D. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not dilated cardiomyopathy (DCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to reduced chamber size and impaired diastolic filling. However, in DCM, the primary abnormality is dilation or enlargement of the ventricles rather than thickening of the ventricular walls.

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A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

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