The nurse is caring for an older adult client who is experiencing delirium. Which of the following should be the priority action by the nurse?
Administer diazepam.
Obtain a medical history.
Start intravenous fluids.
Raise 3 of the 4 side rails of the bed.
The Correct Answer is B
A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.
B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.
C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.
D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.
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Related Questions
Correct Answer is B
Explanation
A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.
B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.
C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.
D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.
Correct Answer is A
Explanation
A. History of abuse: A history of physical, emotional, or sexual abuse is a significant risk factor for developing conduct disorder. Children who have experienced abuse may exhibit aggressive and defiant behaviours as a means of coping with their trauma.
B. Has more than three siblings: Having a large number of siblings alone is not directly associated with conduct disorder. Family dynamics and individual relationships are more relevant than the number of siblings.
C. A structured household environment: A structured household environment, typically characterized by consistent rules and supportive parenting, is generally protective against behavioural disorders like conduct disorder.
D. Diagnosis of many chronic medical illnesses: Chronic medical illnesses are not typically linked to conduct disorder. Risk factors for CD are more commonly related to psychosocial and environmental issues rather than medical conditions
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