Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A 68-year-old client is admitted to the medical unit with suspected Neisseria meningitidis. The client is experiencing acute delirium, severe photophobia, and is repeatedly attempting to climb over the bed rails. Which nursing action represents the safest and most appropriate plan of care?

  1. Initiate droplet precautions, activate a bed-exit alarm, and decrease the lighting in the client's room.Cevap
  2. B
    Secure bilateral soft limb restraints to the movable portion of the bed frame to immediately prevent an unassisted fall.
  3. C
    Place the client in an airborne infection isolation room (AIIR) with mandatory N95 respirator use for all entering staff.
  4. D
    Direct the nursing assistant to evaluate the client's pupillary response and level of consciousness at frequent intervals.

Cevap

The safest plan of care is to initiate droplet precautions, activate a bed-exit alarm, and decrease the lighting in the client's room.
The correct approach safely addresses the transmission risk of the pathogen (droplet precautions), implements a least-restrictive fall prevention strategy (bed alarm), and provides an appropriate comfort measure for photophobia (dim lighting). It follows all safety and regulatory guidelines for nursing care.

Adım Adım Çözüm

1
Identify the transmission route for Neisseria meningitidis.
The pathogen requires droplet precautions.
Meningococcal meningitis is spread through large respiratory secretions.
2
Evaluate the client's safety risk (acute delirium and attempting to climb out of bed).
A least-restrictive safety measure, such as a bed-exit alarm, is required.
Nursing standards mandate attempting and documenting less restrictive alternatives before utilizing physical restraints.
3
Address the client's specific clinical symptoms (severe photophobia).
The environment should be modified by dimming the lights.
Dim lighting prevents symptom exacerbation and reduces environmental stimulation that may worsen delirium.
4
Synthesize the findings to select the option that correctly addresses infection control, injury prevention, and symptom management without violating delegation or restraint protocols.
The correct plan incorporates droplet precautions, a bed alarm, and dimmed lighting.
This comprehensively addresses all safety and comfort needs while adhering to proper nursing scope of practice.

Anahtar Kavram

Accident, Error, and Injury Prevention in Infectious Delirium
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru