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Difficulty: HardMental Health Concepts

An older adult client with a history of major depressive disorder is receiving intravenous antibiotics for severe pneumonia on a medical-surgical unit. During the night shift, the client suddenly becomes extremely restless, repeatedly attempts to climb over the bed rails, and yells, "You are all trying to poison me!" Which action should the practical nurse (PN) take first?

  1. Remain at the bedside and ask an assistive personnel to immediately notify the registered nurse (RN).Answer
  2. B
    Apply bilateral soft wrist restraints to prevent the client from removing the intravenous line.
  3. C
    Attempt to logically reason with the client by explaining that the intravenous fluid is only medication.
  4. D
    Document the behavioral changes as an expected progression of age-related cognitive decline.

Answer

Remain at the bedside and ask an assistive personnel to immediately notify the registered nurse (RN).
The correct answer prioritizes the immediate physical safety of the client while adhering to the practical nurse scope of practice. The sudden onset of paranoia and agitation in an older adult with pneumonia strongly suggests acute delirium, likely due to hypoxia or the systemic infection itself. Because the client is attempting to climb out of bed, they are at an imminent risk for falls. The PN must not leave the client alone; staying at the bedside provides immediate safety through a least-restrictive intervention. Simultaneously, instructing an assistive personnel to notify the RN ensures that the acute medical change is promptly assessed and managed by the appropriate provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The older adult client with an active infection (pneumonia) is exhibiting a sudden onset of extreme restlessness and paranoia.
Recognizing that sudden behavioral changes in the presence of an infection point to acute delirium, which is a medical emergency often caused by hypoxia or systemic infection, rather than a psychiatric baseline issue.
2
Determine the most immediate risk to the client.
The client is actively attempting to climb over the bed rails, placing them at severe risk for a fall and traumatic injury.
Maslow's hierarchy of needs and basic nursing principles dictate that physical safety and injury prevention are the highest immediate priorities.
3
Select the appropriate intervention within the PN scope of practice.
The PN must secure immediate safety by staying with the client while delegating another staff member to alert the RN.
The PN cannot leave an actively agitated and unsafe client alone. Simultaneously, the PN must recognize that this acute change in condition requires a comprehensive assessment by the RN and potentially the healthcare provider.

Key Concept

Prioritizing client safety and recognizing acute delirium in older adults
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Mental Health Concepts

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