A nurse is caring for a client with acute delirium who is experiencing severe sensory overload. The client is highly agitated, attempting to climb over the bed rails, and shouting at shadows on the wall while the room's television is blaring. In what order should the nurse prioritize the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).
- 1Ensure the client's immediate physical safety by securing the environment and preventing a fall.
- 2Reduce environmental stimuli by turning off the television and minimizing harsh lighting.
- 3Approach the client slowly from a visible angle while using a calm, low-pitched voice.
- 4Offer simple, concise statements to reorient the client to reality and provide reassurance.
- 5Administer the prescribed PRN antipsychotic medication if non-pharmacological measures fail.
Cevap
The correct sequence is to first ensure physical safety, second reduce environmental stimuli, third approach the client calmly, fourth provide verbal reorientation, and fifth administer medication as a last resort.
The correct sequence follows the nursing process and prioritization frameworks. The nurse must first ensure immediate physical safety to prevent injury from falling. Next, the nurse addresses the root cause of the immediate distress by eliminating excessive sensory stimuli (turning off the TV, adjusting lights). Once the environment is calm, the nurse can safely approach the client in a non-threatening manner. After establishing a presence, verbal reorientation using simple terms is appropriate. Finally, if these less restrictive, non-pharmacological interventions are ineffective at managing the severe agitation, PRN medication is administered as a last resort.
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Anahtar Kavram
Prioritization of care for a client experiencing acute sensory overload and delirium, utilizing the principles of safety, least restrictive interventions, and environmental modification.
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