Examkin

Soru

Zorluk: ZorMental Health Concepts

An older adult client with a history of mild dementia is receiving intravenous antibiotics for a severe lower respiratory tract infection. The client suddenly exhibits profound restlessness, fails to recognize familiar staff, and attempts to pull out the intravenous (IV) line while shouting, "Get away from me! You are trying to capture me!" Which action should the practical nurse (PN) take first?

  1. A
    Document the client's acute agitation as an anticipated manifestation of their preexisting neurocognitive disorder.
  2. Maintain a calm presence at the bedside, gently redirect the client's hands away from the intravenous line, and use simple statements to present reality.Cevap
  3. C
    Inquire of the client, "Why do you believe the nursing staff is trying to capture you?"
  4. D
    Prepare to apply bilateral soft wrist restraints immediately to protect the integrity of the critical intravenous line.

Cevap

Maintain a calm presence at the bedside, gently redirect the client's hands away from the intravenous line, and use simple statements to present reality.
The priority action is to ensure the client's immediate physical safety while employing the least restrictive intervention possible. Remaining at the bedside and gently redirecting the client's hands protects the intravenous line without the use of physical restraints. Furthermore, using a calm voice and simple statements helps to present reality and de-escalate the acute anxiety and perceptual disturbances associated with delirium.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and medical history.
The client has a history of mild dementia but is experiencing a sudden, severe change in cognition and behavior while being treated for an infection.
Sudden onset of confusion and agitation in an older adult with an infection is a hallmark sign of acute delirium, not a typical progression of baseline dementia.
2
Identify the most immediate threat to the client.
The client is actively attempting to pull out their intravenous line, which poses an immediate safety risk and threatens their medical treatment.
Prioritization in nursing care always begins with immediate physical safety and the preservation of critical medical interventions.
3
Select the nursing intervention that addresses the threat using the least restrictive method.
The PN chooses to stay at the bedside, gently guide the client's hands away, and verbally reorient them.
Safe, ethical practice mandates utilizing the least restrictive environment. Physical redirection and therapeutic presence must be attempted before advancing to chemical or physical restraints.

Anahtar Kavram

Prioritizing least restrictive safety measures and recognizing acute delirium in older adults
Tahmini Süre:1m 15s
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Mental Health Concepts

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