An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
Administer a prescribed PRN benzodiazepine at the onset of a confused state.
Ensure that the client is assigned to a room close to the nurses' station.
Postpone administration of nighttime medications until after 2300.
Ask family members to remain with the client in the evenings from 1700 to 2000.
The Correct Answer is B
A. Administering a PRN benzodiazepine is a reactive measure and might not be the best first line of intervention for managing the client's restlessness and confusion, as it does not address the underlying issue.
B. Assigning the client to a room close to the nurses' station can help manage restlessness, confusion, and agitation by ensuring the client is monitored more closely and can receive timely interventions.
C. Postponing nighttime medications might not address the immediate issues of restlessness and confusion, and could potentially disrupt the client's sleep-wake cycle.
D. Asking family members to stay with the client provides support but may not be a feasible or consistent solution for managing the client’s evening agitation and restlessness.
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Related Questions
Correct Answer is B
Explanation
A. Reviewing the prognosis for the spouse does not address the immediate concern about the influenza vaccination’s impact on the spouse’s health.
B. Explaining that the influenza vaccination will actually help reduce the risk of transmission of influenza to the spouse undergoing chemotherapy addresses the client’s concern and provides accurate information.
C. Planning the vaccination for a day when the spouse is not receiving chemotherapy does not resolve the underlying issue of the vaccination’s effectiveness and safety.
D. Determining when the spouse will finish chemotherapy is not relevant to the immediate concern of the vaccination and its effects on the spouse’s health.
Correct Answer is D
Explanation
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
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