During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client's upper and lower extremities. Which intervention is most important for the nurse to implement on admission?

Assess peripheral oxygen saturation.

Determine baseline neurologic status.

Schedule a sitter around the clock.

Administer an IV anxiolytic medication.

Answer and Explanation

The Correct Answer is B

A. Assess peripheral oxygen saturation: While evaluating oxygenation is important in altered mental status, it is not the priority after restraints have been applied. Oxygen saturation may contribute to confusion, but neurological assessment is more directly relevant.

B. Determine baseline neurologic status: Establishing a neurological baseline is crucial after a sudden change in consciousness and behavior. It helps monitor for further deterioration or improvement and guides decisions about restraint necessity and care interventions.

C. Schedule a sitter around the clock: A sitter may be needed, but this decision should be based on a full assessment of the client’s condition and risk factors. It is not the first priority immediately after application of restraints.

D. Administer an IV anxiolytic medication: Medication may be considered later if the behavior persists or worsens, but it must be based on assessment findings and provider orders. The initial focus should be on identifying the underlying cause of the behavioral change.

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Correct Answer is D

Explanation

A. Review the pain medications prescribed: Reviewing available medications is useful for planning, but it should follow a more direct exploration of the client's current discomfort and verbal input.

B. Administer PRN oral pain medication: Administering medication without the client reporting pain or confirming the need can be inappropriate, especially if the client denies discomfort. Further assessment is needed first.

C. Monitor the client's nonverbal behavior: Continued observation is important but passive. The nurse should actively seek clarification to determine if intervention is needed.

D. Ask the client what is causing the grimacing: This approach respects the client's autonomy and provides an opportunity to explore the cause of the discomfort. It helps clarify if the grimacing is due to pain or another issue, guiding appropriate next steps.

A. Demonstrate the skill, speaking slowly and using simple terms. B. Reduce the stimuli in the area before continuing the teaching. C. Reassure the client that the skill is not difficult to learn. D. Provide the client with step-by-step written instructions.

Correct Answer is B

Explanation

A. Demonstrate the skill, speaking slowly and using simple terms: Although simplifying the language and demonstrating may help in general, it does not address the root problem of sensory overload. The client is already overstimulated, and adding more input can further hinder learning.

B. Reduce the stimuli in the area before continuing the teaching: Reducing environmental stimuli, such as noise, bright lights, or background activity, helps calm the client and allows their cognitive focus to return. This approach directly addresses sensory overload and creates a more conducive environment for learning.

C. Reassure the client that the skill is not difficult to learn: Reassurance may comfort the client emotionally, but it does not resolve the issue of excessive sensory input that interferes with cognitive processing and concentration.

D. Provide the client with step-by-step written instructions: Written instructions may be helpful later, but they still require mental focus to process. If the client is experiencing sensory overload, written materials alone will not be effective until the environment is optimized.

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Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is B

Explanation

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