A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?

Start intravenous fluids.

Administer diazepam.

Obtain a medical history.

Raise the side rails of the bed.

Answer and Explanation

The Correct Answer is D

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Correct Answer is A

Explanation

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

A. The client responds to questions with disorganized speech:

Disorganized speech is a hallmark of acute mania, often reflecting racing thoughts, pressured speech, and difficulty staying on topic.

B. The client reports that voices are telling him to write a novel:

Reporting that voices are telling the client to write a novel suggests auditory hallucinations, which can occur in various psychiatric conditions, not specifically indicative of acute mania.

C. The client's spouse reports that the client has recently gained weight:

Weight gain is not a typical hallmark of acute mania. In fact, during manic episodes, individuals might experience decreased appetite and sleep, leading to potential weight loss.

D. The client is dressed in all black:

Dressing in all black is not a specific sign of acute mania. While changes in clothing choices or appearance can sometimes be associated with mood changes, this finding alone is not indicative of acute mania.

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A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?

Nursing Test Bank

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