An older female client who received additional prescription medications is becoming increasingly confused during the night. The client is found wandering the hallway describing someone is in her room trying to hurt her. Prior to notifying the healthcare provider, which intervention(s) should the nurse implement? Select all that apply.

Assess the client's understanding of the new medications.

Notify the charge nurse of the client's disorientation.

Document the client's hallucinations.

Reorient the client to time and space.

Restrain the client in her room using soft restraints.

Answer and Explanation

Correct Answer : B,C,D

Rationale:
A. Assess the client's understanding of the new medications: While medication reconciliation is important later, you cannot assess the "understanding" of a client who is currently in an acute state of confusion and hallucinating. The immediate focus must be on safety and stabilization.

B. Notify the charge nurse of the client's disorientation: Alerting the charge nurse ensures appropriate support, timely assessment, and coordination of care. Early communication is important for patient safety and rapid intervention if the client’s behavior escalates.

C. Document the client's hallucinations: Accurate documentation of observed behaviors and hallucinations provides critical information for the healthcare provider to assess potential causes, including adverse drug reactions, infection, or delirium. Documentation is essential for safe and effective care planning.

D. Reorient the client to time and space: Providing verbal reassurance and cues about the environment helps reduce anxiety, supports cognitive orientation, and may decrease agitation. Nonpharmacologic interventions are first-line strategies for managing acute confusion in older adults.

E. Restrain the client in her room using soft restraints: Physical restraints should be a last resort due to the risk of injury, increased agitation, and ethical considerations. Restraints are not indicated prior to attempting assessment, reorientation, and nonpharmacologic safety measures.

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Correct Answer is C

Explanation

Rationale:
A. Lip smacking and frequent eye blinking: These are signs of tardive dyskinesia, a potential long-term side effect of antipsychotic medications. While concerning and requiring monitoring, they are not immediately life-threatening and can be reported and evaluated during routine care.

B. Rocks back and forth in the chair: Rocking behavior is a common self-soothing or repetitive movement in clients with schizophrenia. It is not acutely dangerous and does not require emergency intervention. Monitoring is appropriate.

C. Muscle spasms of the back and neck: Acute muscle spasms, particularly of the neck (torticollis) or back, may indicate an extrapyramidal reaction (acute dystonia) from antipsychotic therapy. This condition can be painful, distressing, and interfere with airway and mobility, requiring immediate medical and nursing intervention to prevent complications.

D. Shuffling gait and stooped posture: These are signs of parkinsonism associated with long-term antipsychotic use. While affecting mobility and quality of life, they do not require immediate intervention. Management involves adjustment of medications over time.

A. Morphine. B. Aspirin. C. Nitroglycerin. D. Heparin.

Correct Answer is C

Explanation

Rationale:
A. Morphine: Morphine can be safely administered for pain management in chest pain or myocardial infarction and does not interact dangerously with sildenafil. It is not contraindicated in this scenario.

B. Aspirin: Aspirin is used to reduce platelet aggregation and prevent further thrombus formation during acute coronary syndromes. It does not have a dangerous interaction with sildenafil and can be administered safely.

C. Nitroglycerin: Nitroglycerin is contraindicated in clients who have recently taken sildenafil (Viagra) because the combination can cause profound hypotension and cardiovascular collapse. The nurse should withhold nitroglycerin until a safe interval has passed since sildenafil administration.

D. Heparin: Heparin is an anticoagulant used in the management of acute coronary syndromes or thromboembolic events. It does not interact with sildenafil and can be administered safely according to protocol.

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Explanation

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Correct Answer is C

Explanation

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