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Zorluk: OrtaHigh Risk Behaviors

A home healthcare RN is evaluating an older adult client who lives independently. During the medication reconciliation, the client reports consuming half a bottle of whiskey daily along with a prescribed dose of lorazepam for anxiety. Which of the following nursing interventions should the RN include in the client's plan of care? (Select all that apply.)

  1. Screen the client for underlying depression and suicidal ideation.Cevap
  2. Educate the client about the synergistic central nervous system depressant effects of alcohol and lorazepam.Cevap
  3. Conduct a comprehensive fall risk assessment of the client's home environment.Cevap
  4. D
    Reassure the client that experiencing episodes of morning confusion is a normal physiological change associated with aging.
  5. E
    Ask the client, 'Why do you feel the need to consume whiskey every single day?'
  6. F
    Delegate the initial assessment of the client's potential alcohol withdrawal symptoms to an unlicensed assistive personnel.

Cevap

The correct interventions are to screen for depression and suicidal ideation, educate on the synergistic effects of central nervous system depressants, and conduct a comprehensive fall risk assessment.
The correct interventions prioritize client safety, mental health, and harm reduction education. Screening for depression and suicidal ideation is crucial because older adults who misuse substances often have underlying and untreated mental health disorders. Educating the client about the synergistic central nervous system (CNS) depressant effects of alcohol and lorazepam is a primary harm reduction strategy to prevent fatal respiratory depression. Furthermore, conducting a comprehensive fall risk assessment is essential, as the combination of advanced age, alcohol intoxication, and benzodiazepine use severely impairs balance and coordination.

Adım Adım Çözüm

1
Analyze the client's risk factors based on the provided scenario.
The client is an older adult mixing a significant amount of alcohol (whiskey) with a prescription benzodiazepine (lorazepam).
Identifying the overlapping risk factors (advanced age, heavy alcohol consumption, prescription CNS depressants) is necessary to determine appropriate safety and educational interventions.
2
Evaluate the clinical appropriateness of the positive nursing interventions.
Screening for depression, teaching about drug-alcohol interactions, and assessing fall risk directly address the client's immediate life-threatening and psychosocial risks.
Nurses must prioritize interventions that address physiological safety, psychological well-being, and high-risk medication interactions.
3
Identify and eliminate contraindicated or non-therapeutic actions.
Dismiss options that involve normalizing pathological confusion, using non-therapeutic 'why' questions, or improperly delegating initial assessments to unlicensed staff.
Recognizing common nursing errors ensures that the plan of care remains safe, therapeutic, and legally sound.

Anahtar Kavram

High-risk behaviors involving substance misuse in the older adult population require prioritization of safety, mental health screening, and the avoidance of non-therapeutic communication or improper task delegation.
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High Risk Behaviors

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