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Zorluk: ZorBasic Care and Comfort

An 82-year-old client with a history of vascular dementia is receiving continuous enteral nutrition through a nasoenteric tube. The client becomes acutely restless, repeatedly attempts to swing their legs over the edge of the bed, and pulls at the nasal tubing. Which action should the registered nurse take first?

  1. Assess the client for a full bladder and provide a folded washcloth for the client to manipulate.Cevap
  2. B
    Reposition the bed into a flat, horizontal alignment to make it more difficult for the client to exit the bed.
  3. C
    Delegate to the assistive personnel the task of evaluating the client's sudden change in orientation.
  4. D
    Obtain a prescription to apply bilateral limb holders to prevent the immediate dislodgement of the feeding tube.

Cevap

The correct action is to assess the client for a full bladder and provide a folded washcloth for the client to manipulate.
When a client with dementia exhibits acute restlessness, the nurse should first use the nursing process to assess for underlying physiological triggers, such as urinary retention or pain. Providing a folded washcloth is a therapeutic, least-restrictive intervention that safely redirects the client's manual focus away from the medical tubing while the nurse addresses their basic care needs.

Adım Adım Çözüm

1
Identify the client's immediate risks based on the clinical presentation.
The client is at high risk for self-extubation of the feeding tube and falls due to acute restlessness.
Establishing the primary safety threats directs the prioritization of care.
2
Recognize the standard nursing principles for managing sudden agitation in clients with dementia.
Acute agitation often indicates an unmet physiological need, such as a full bladder, constipation, pain, or hypoxia.
Identifying the root cause using the nursing process (assessment) is required before implementing symptom-masking interventions.
3
Evaluate the safety and appropriateness of the proposed alternative interventions.
Laying the client flat introduces a critical aspiration risk. Delegating the assessment violates scope of practice. Applying restraints skips mandatory less-restrictive protocols.
Each distractor represents a severe safety violation or breach of nursing standards.
4
Select the intervention that addresses the underlying cause and provides a safe, least-restrictive alternative.
Assessing elimination needs and offering a tactile distraction is prioritized.
This action aligns with standard basic care and comfort guidelines for protecting medical devices without resorting to chemical or physical restraints.

Anahtar Kavram

Management of Acute Agitation and Enteral Feeding Safety
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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