An older adult client receiving continuous bladder irrigation (CBI) following a prostate resection develops sudden, severe confusion. The client is highly restless, repeatedly attempting to pull out the three-way urinary catheter, and trying to climb over the bed rails. Which interventions should the practical nurse (PN) implement to maintain client safety? Select all that apply.
- Provide a repetitive diversionary activity, such as folding towels, to occupy the client's hands.Cevap
- Conceal the three-way catheter tubing beneath the client's hospital gown and bed linens.Cevap
- Assign an available unlicensed assistive personnel (UAP) to provide one-to-one continuous observation.Cevap
- DApply soft limb restraints to the client's wrists to prevent dislodgement of the catheter.
- EAttribute the sudden onset of confusion to expected age-related dementia and document the behavior.
- FPerform an initial comprehensive psychological assessment to establish the exact etiology of the delirium.
Cevap
The correct interventions are to provide a diversionary activity, conceal the catheter tubing, and assign a UAP for one-to-one observation.
The correct choices represent the least restrictive alternatives for maintaining the safety of a confused client. Concealing the tubing removes the visual trigger, diversionary activities occupy the client's hands safely, and a dedicated sitter provides immediate redirection, all of which protect the client and the medical device without resorting to physical restraints.
Adım Adım Çözüm
Anahtar Kavram
Prioritizing least restrictive restraint alternatives and adhering to the PN scope of practice during acute client delirium.