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Zorluk: OrtaAccident, Error, and Injury Prevention

During the night shift on a medical-surgical unit, an 84-year-old client who was previously alert and cooperative suddenly becomes disoriented, wanders into the hallway, and attempts to open a restricted stairwell door. Which action is the priority for the practical nurse to take to prevent client injury?

  1. A
    Document the nighttime wandering as an expected age-related cognitive change.
  2. B
    Apply a soft belt restraint to keep the client safely in bed for the remainder of the night.
  3. C
    Instruct the unlicensed assistive personnel to administer an intravenous sedative medication.
  4. Redirect the client to their room and immediately assess vital signs and oxygen saturation.Cevap

Cevap

The priority action is to redirect the client to their room and immediately assess vital signs and oxygen saturation.
Sudden confusion and wandering in an older adult often signal a physiological disturbance such as hypoxia, infection, or a medication adverse effect. The priority is to secure the client's immediate safety by redirecting them, followed immediately by an assessment of vital signs to identify and treat the underlying cause of the acute delirium.

Adım Adım Çözüm

1
Identify the sudden change in the client's mental status.
The acute onset of disorientation indicates potential delirium rather than baseline chronic dementia.
Recognizing acute delirium is critical because it often stems from reversible, life-threatening physiological stressors.
2
Prioritize immediate safety and physiological assessment over restraints.
The nurse safely redirects the client away from the hazard (stairwell) and begins a physiological workup.
Securing the client's immediate environment prevents physical harm, while checking vital signs identifies potential physiological causes like hypoxia or infection.

Anahtar Kavram

Prioritization of safety and physiological assessment in acute delirium
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Konular

Accident, Error, and Injury Prevention

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