During the night shift at a rehabilitative care center, a practical nurse (PN) is rounding on a senior client who is recovering from orthopedic surgery. The client's admission record indicates a history of heavy, daily alcohol consumption prior to the injury. On the third day of admission, the PN finds the client intensely restless, sweating profusely, and brushing imaginary insects off the bed linens. Which action is the priority for the PN to implement?
- Stay in the room to ensure safety and use the call light to urgently notify the registered nurse (RN).Cevap
- BExplain logically to the client that the insects are not real and are a trick of the mind.
- CNote the sudden confusion in the chart as an expected age-related reaction to a new facility.
- DDelegate continuous observation to an unlicensed assistive personnel (UAP) while leaving to retrieve restraints.
Cevap
The priority action is to stay in the room to ensure safety and use the call light to urgently notify the registered nurse (RN).
The client's presentation of profound restlessness, diaphoresis, and visual/tactile hallucinations 48 to 72 hours after admission points directly to alcohol withdrawal delirium (delirium tremens). This is a life-threatening emergency. The highest priority for the practical nurse (PN) is to maintain the client's physical safety by remaining at the bedside while simultaneously alerting the registered nurse (RN) to initiate emergency medical protocols.
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Anahtar Kavram
Alcohol Withdrawal Delirium (Delirium Tremens) and Safety Prioritization