A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Administer medication to sedate the client.
Call the family and ask them to stay with the client.
Apply wrist and leg restraints to the client.
Move the client to a room closer to the nurses' station.
The Correct Answer is D
Choice A rationale:
Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.
Choice B rationale:
Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.
Choice C rationale:
Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.
Choice D rationale:
Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Encouraging the family to take the client out of the facility for short periods of time may not be appropriate at this point. Abrupt changes in behavior, like sudden cheerfulness, might be a warning sign for potential suicide risk in individuals with depression. Allowing the client to leave the facility could increase the risk of harm.
Choice B rationale:
Rewarding the client for the change in behavior might inadvertently reinforce the idea that acting cheerful is desirable. This could hinder the client's progress and therapeutic understanding of their condition.
Choice C rationale:
Asking the client why her behavior has changed is a thoughtful and reasonable approach, but it might not address the potential underlying issues adequately. Depression can still be present, and sudden shifts in mood should be monitored closely.
Choice D rationale:
Monitoring the client's whereabouts at all times is the appropriate action. Sudden improvements in a depressed client's demeanor could indicate that they have made a decision to end their life. Monitoring ensures their safety and enables prompt intervention if needed.
Correct Answer is B
Explanation
Choice A rationale:
The statement "I know that men who are abusers gain power through intimidation." is accurate and aligned with the understanding of domestic violence dynamics. Abusers often use intimidation tactics to exert control over their victims, perpetuating a cycle of power and control.
Choice B rationale:
The statement "I have heard that abusers think of themselves as important and have high self-esteem." needs clarification. This statement is not entirely accurate. Abusers may display a façade of high self-esteem, but beneath it, they often have deep-seated insecurities. It's important to highlight that abusive behavior stems from a desire to control and dominate, rather than genuine self-worth.
Choice C rationale:
The statement "I know that abusers lack social supports and social skills." is inaccurate. Abusers can have social supports and social skills. Domestic violence is not solely determined by the lack of social skills or support; it is a complex issue rooted in power dynamics and learned behaviors.
Choice D rationale:
The statement "I have heard that abusers try to keep their partner isolated from others." is accurate and aligned with the understanding of domestic violence dynamics. Abusers frequently isolate their partners to maintain control over them, making it difficult for victims to seek help or support from others.
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