What does a score of 6 on the Katz Index of Independence in Activities of Daily Living (ADLs) indicate?

A. Interpersonal: The nurse is engaging in interpersonal communication during the admission health history and physical assessment. This form of communication occurs between two individuals and involves a direct exchange of information, thoughts, and feelings. The nurse and the patient interact in a one-on-one setting to gather health information and build rapport.

B. Intrapersonal: Intrapersonal communication refers to communication that occurs within an individual, such as self-talk or internal dialogue. This is not the form of communication used during the nurse's interaction with the patient.

C. Group: Group communication involves interactions among multiple individuals, such as a discussion or meeting with several participants. This does not apply to the nurse's one-on-one interview with the patient.

D. Small group: Small group communication typically involves a few people discussing or working together on a task or topic. Although the nurse may participate in small group discussions, the specific interaction during the admission assessment is classified as interpersonal communication.

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.