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Difficulty: MediumBasic Care and Comfort

During the night shift, a registered nurse is called to the room of an 84-year-old client admitted with community-acquired pneumonia. The client has suddenly become severely agitated, is pulling at the intravenous (IV) tubing, and is attempting to get out of bed unassisted. Which of the following is the most appropriate initial nursing action?

  1. Determine if the client has unmet physiological needs, such as a full bladder or pain, and initiate a bed alarm system.Answer
  2. B
    Direct the unlicensed assistive personnel (UAP) to assess the client's neurological status and evaluate the IV site.
  3. C
    Apply bilateral soft wrist restraints to secure the client's arms and prevent accidental dislodgement of the IV infusion.
  4. D
    Document the sudden onset of confusion as a standard, expected cognitive change related to the normal aging process.

Answer

Determine if the client has unmet physiological needs, such as a full bladder or pain, and initiate a bed alarm system.
Sudden agitation in an older adult is highly suggestive of delirium, which is frequently triggered by unmet basic physiological needs such as a full bladder, pain, or hypoxia. The primary role of the nurse in promoting basic care and comfort is to identify and resolve these underlying issues while implementing the least restrictive safety measures possible, such as a bed alarm, to protect the client.

Step-by-Step Solution

1
Recognize the clinical presentation.
The older adult client is exhibiting sudden severe agitation, confusion, and unsafe behaviors.
Identifying acute changes in mental status is critical, as they often point to underlying, reversible physiological problems rather than chronic cognitive decline.
2
Prioritize nursing interventions based on the least restrictive environment and fundamental care needs.
The nurse plans to assess for reversible causes (e.g., full bladder, hypoxia, pain) and utilize a bed alarm rather than immediately applying physical restraints.
Basic care and comfort principles dictate that addressing fundamental physiological needs and using non-pharmacological, non-restrictive measures must occur before escalating to restraints.

Key Concept

Basic Care and Comfort: Non-Pharmacological Comfort and Safety in Delirium
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Topics

Basic Care and Comfort

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