A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?
Determine the client's level of consciousness
Administer an anxiolytic medication.
Keep lights on in the client's room.
Encourage visits from family members.
The Correct Answer is A
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Restraining the child's upper extremities is not recommended. It's important to allow the child to move freely during the seizure to prevent injury. Attempting to restrain their movements could result in harm to the child or the person attempting to restrain them.
Choice B Reason:
Turning the child onto their back is generally appropriate as long as you do it gently and without force. It helps ensure that the airway remains clear and allows any fluids to drain out of the mouth. However, you should not forcibly turn the child; instead, gently guide them if necessary.
Choice C Reason:
Placing a padded tongue blade or any object in the child's mouth is strongly discouraged during a seizure. Doing so can result in injury to the child's mouth, teeth, or jaw. It is a common misconception that someone might swallow their tongue during a seizure, but this rarely happens. It's essential to keep the child's airway clear but not to insert any objects into their mouth.
D. Placing a pillow under the child's head is appropriate to protect their head from injury, especially if they are on a hard surface. It can help cushion the head and reduce the risk of head trauma during the seizure.
Correct Answer is A
Explanation
Choice A Reason:
Incident report is correct .When a medication error occurs, it should be documented in an incident report. An incident report is a formal record of an event that compromises client safety, such as a medication error. It allows the healthcare facility to investigate the error, take corrective actions, and implement preventive measures to improve patient safety. Incident reports are generally kept separate from the client's medical record to protect the confidentiality of the investigation.
Choice B Reason:
Controlled substance inventory record is incorrect. This record is used to track the administration and wastage of controlled substances and is not the appropriate place to document a medication error.
Choice C Reason:
Provider's progress notes is incorrect. The provider's progress notes are used for documenting the client's medical history, physical examination, diagnosis, treatment plan, and progress. It is not the place to document medication errors.
Choice D Reason:
Nursing care plan is incorrect. The nursing care plan outlines the client's nursing diagnoses, goals, interventions, and outcomes. It is not the appropriate place to document medication errors.
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