Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A practical nurse is providing care for a geriatric client on a medical unit. The client, who was previously oriented and cooperative, abruptly begins thrashing in bed, exhibiting rapid breathing, and attempting to climb over the side rails. Which intervention is the priority for the nurse to ensure client safety?

  1. A
    Apply soft wrist restraints immediately to physically prevent the client from climbing out of bed.
  2. B
    Record the abrupt agitation as a standard symptom of geriatric decline and encourage the client to rest.
  3. Check the client's oxygen saturation and vital signs while immediately notifying the registered nurse (RN).Cevap
  4. D
    Instruct the unlicensed assistive personnel (UAP) to independently evaluate the client's respiratory status.

Cevap

The priority action is to check the client's oxygen saturation and vital signs while immediately notifying the registered nurse (RN).
The sudden onset of confusion, restlessness, and rapid breathing (tachypnea) in a geriatric client is a hallmark sign of an acute physiological compromise, such as hypoxia. The practical nurse's priority to prevent injury is to quickly gather objective data (vital signs) and escalate the unstable client's condition to the registered nurse (RN) for rapid medical intervention. Addressing the underlying physiological cause is the most effective and safest way to resolve the agitation.

Adım Adım Çözüm

1
Analyze the client's sudden change in behavior and respiratory status.
The abrupt onset of confusion, thrashing, and rapid breathing points to an acute physiological problem (such as hypoxia or infection) rather than a simple behavioral issue.
Identifying the root cause of sudden behavioral changes is essential for applying the correct safety and medical interventions.
2
Determine the appropriate nursing intervention and scope of practice.
The practical nurse must collect immediate objective data (vital signs) and escalate this critical change to the registered nurse (RN).
Acute instability requires rapid collaboration between the practical nurse, registered nurse, and provider to resolve the life-threatening cause of the agitation.
3
Evaluate the distractors against established safety protocols.
Applying restraints bypasses less restrictive alternatives. Delegating assessment to a UAP violates scope of practice. Normalizing the symptoms dangerously ignores an acute crisis.
Client safety is best maintained by addressing the physiological threat, not by treating the symptom with unsafe shortcuts.

Anahtar Kavram

Identifying Acute Delirium and Prioritizing Physiological Safety
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru