A practical nurse (PN) is assigned to an older adult client admitted yesterday for treatment of a systemic urinary tract infection. The client, whose baseline mental status is documented as alert and fully oriented, suddenly becomes highly agitated, loudly demands to leave, and attempts to climb over the raised side rails of the bed. The client's medication profile includes a newly prescribed, as-needed (PRN) order for intravenous haloperidol for severe agitation. To ensure client safety and prevent immediate injury, which action is the priority for the PN?
- Maintain a continuous physical presence at the bedside, gently guide the client to a safe position, and direct assistive personnel to urgently retrieve the registered nurse.Cevap
- BPromptly prepare and administer the prescribed intravenous haloperidol to rapidly chemically de-escalate the client and mitigate the high risk of a traumatic fall.
- CImmediately secure the client to the bed using a soft belt restraint to prevent an unobserved fall, then contact the healthcare provider to report the emergency intervention.
- DRecognize the sudden agitation as expected sundowning related to advanced age and hospitalization, dim the overhead lights, and provide calm verbal reassurance.
Cevap
Maintain a continuous physical presence at the bedside, gently guide the client to a safe position, and direct assistive personnel to urgently retrieve the registered nurse.
The correct action directly mitigates the imminent fall risk using the least restrictive measure (direct observation) while adhering to the PN scope of practice by delegating the administration of the IV push medication to the RN, who is authorized to manage both the medication and the acute assessment of delirium.
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Anahtar Kavram
The practical nurse must balance immediate injury prevention using least restrictive alternatives with strict adherence to their legal scope of practice during acute client changes.