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 ["A","B","E"]
Explanation
Answer and explanation
The correct answers are choices A. Depression, B. Obsessive-compulsive disorder, E. Anxiety.
Choice A rationale:
Depression commonly coexists with eating disorders. The individual's distorted body image, feelings of low self-worth, and dietary restrictions can contribute to the development of depressive symptoms.

Choice B rationale:
Obsessive-compulsive disorder (OCD) often occurs alongside eating disorders. The obsessions and compulsions seen in OCD can overlap with behaviors related to food, eating rituals, and body image, reinforcing the eating disorder pathology.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves disruptions in thought processes, emotions, and perceptions, which are distinct from the cognitive distortions and behaviors associated with eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a commonly recognized comorbidity of eating disorders. While sleep disturbances might occur in individuals with eating disorders due to physical discomfort or anxiety, a specific link to breathing-related sleep disorder is less established.
Choice E rationale:
Anxiety is a well-recognized comorbidity of eating disorders. Anxiety often accompanies the intense fears, worries, and preoccupations related to body weight, shape, and eating behaviors that are characteristic of eating disorders.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.
Choice B rationale:
Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.
Choice C rationale:
Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.
Choice D rationale:
Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.
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