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Zorluk: OrtaBasic Care and Comfort

A 75-year-old client is prescribed prolonged bed rest and has an indwelling urinary catheter in place. The client, who has been previously cooperative and oriented, suddenly becomes severely agitated and repeatedly pulls at the catheter tubing. Which intervention is the most appropriate for the nurse to perform?

  1. Inspect the catheter tubing for any kinks or blockages and gently palpate the client's suprapubic area for bladder distention.Cevap
  2. B
    Apply bilateral soft wrist restraints immediately to prevent the client from successfully dislodging the invasive device.
  3. C
    Educate the client's family members that sudden agitation is a normal, expected part of the aging process during hospitalization.
  4. D
    Delegate the task of evaluating the client's urethral meatus and surrounding tissue for signs of injury to the unlicensed assistive personnel (UAP).

Cevap

Inspect the catheter tubing for any kinks or blockages and gently palpate the client's suprapubic area for bladder distention.
The correct answer focuses on identifying and resolving the physiological source of the client's distress. In older adults, sudden agitation is frequently a behavioral manifestation of an unmet basic care need, such as pain or a full bladder. Checking the catheter for patency and the bladder for distention addresses the most likely cause of the discomfort.

Adım Adım Çözüm

1
Analyze the client's sudden change in behavior.
The client has transitioned rapidly from being cooperative to severely agitated, specifically targeting the urinary catheter.
Sudden behavioral changes in older adults often stem from unmet basic physiological needs or acute, unexpressed physical discomfort.
2
Identify potential sources of physical discomfort related to the client's specific actions.
The client is pulling at the catheter, strongly suggesting localized discomfort in the bladder or urethral area.
A blocked, kinked, or clamped catheter causes urine to accumulate in the bladder, leading to painful distention and severe agitation.
3
Determine the most appropriate basic care nursing intervention.
The nurse must immediately assess the equipment for patency and the client's abdomen for a full bladder.
Resolving the physical discomfort by restoring normal urine flow directly addresses the root cause of the agitation.

Anahtar Kavram

Recognizing physical discomfort and elimination issues as primary causes of acute agitation in older adults.
Tahmini Süre:1m 15s
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Basic Care and Comfort

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