An 82-year-old client is hospitalized with a severe urinary tract infection and has been receiving intravenous (IV) hydration and scheduled oral diphenhydramine for a localized rash over the past 48 hours. During morning rounds, the practical nurse (PN) finds the client newly agitated, disoriented to place, and actively pulling at the IV catheter. The next scheduled dose of diphenhydramine is currently due. Which action should the PN take first?
- Withhold the scheduled diphenhydramine, remain with the client to maintain safety, and immediately notify the registered nurse (RN).Answer
- BAdminister the medication as prescribed, assuming the client's sudden confusion is a normal expectation of the aging process.
- CApply physical wrist restraints to secure the client's hands before attempting any less restrictive alternative measures.
- DIndependently conduct a comprehensive neurological assessment to diagnose the exact cause of the altered mental status.
Answer
The practical nurse should withhold the scheduled diphenhydramine, stay with the client to prevent harm, and promptly inform the registered nurse of the acute status change.
The correct answer identifies that the older adult client is experiencing acute delirium, a medical emergency often triggered or exacerbated by anticholinergic medications like diphenhydramine. The practical nurse must prioritize safety by remaining with the client, withholding the potentially harmful medication to prevent further deterioration, and immediately notifying the registered nurse to facilitate a prompt, comprehensive clinical evaluation.
Step-by-Step Solution
Key Concept
Recognizing adverse anticholinergic drug effects in older adults and adhering to the practical nurse scope of practice during an acute clinical change.