A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Apply soft restraints to wrists and chest.

Administer antipsychotic medications as prescribed.

Administer sedative medications as prescribed.

Arrange for one-on-one observation for the client.

Answer and Explanation

The Correct Answer is D

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.

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Correct Answer is C

Explanation

Answer: C. "I am not worried. This sort of thing happens all the time to us 'old people.'"

A. "I brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
This response indicates understanding and proactive involvement in the client’s care. An updated medication list is crucial in evaluating potential causes of delirium, as certain medications or interactions can contribute to changes in mental status.

B. "I notified our family members that they should not come visit for a while, until they are better."
This statement reflects an understanding of the need for a calm environment for the client experiencing delirium. Reducing stimuli and visitors can help the client focus on recovery. It indicates the spouse is aware of the potential impact of social interactions on the client’s condition.

C. "I am not worried. This sort of thing happens all the time to us 'old people.'"
This response indicates a need for further teaching. It reflects a possible misunderstanding of delirium as a normal part of aging, which can be dismissive of the seriousness of the condition. Delirium is often a sign of underlying medical issues and should be treated with concern and urgency. Clients and their families need to understand that delirium is not a typical or benign occurrence and requires appropriate evaluation and intervention.

D. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
This statement indicates a hopeful attitude while acknowledging the difficulty of the situation. It shows understanding that recovery is possible and reflects the spouse's emotional processing of the situation. Maintaining a positive outlook can be beneficial for both the client and the family during recovery.

A. Increased number of individuals utilizing technology in their homes B. Increased number of the population living longer C. Increased number of Americans over the age of 65 D. Increased number of the population traveling abroad E. Increased number of Americans attending college

Correct Answer is ["B","C"]

Explanation

A. Increased number of individuals utilizing technology in their homes: While technology use may impact various aspects of cognitive function and mental health, there is insufficient evidence to suggest a direct correlation between technology use and the growing numbers of clients diagnosed with dementia.

B. Increased number of the population living longer: One of the primary risk factors for dementia is advancing age. As the population ages and life expectancy increases, there is a higher prevalence of dementia due to the age-related degenerative changes in the brain.

C. Increased number of Americans over the age of 65: Aging is the most significant risk factor for dementia. The aging population, particularly those over 65 years old, is experiencing a higher prevalence of dementia due to age-related changes in the brain.

D. Increased number of the population traveling abroad: There is no direct association between traveling abroad and the growing numbers of clients diagnosed with dementia in the United States. While certain environmental factors or exposures may influence dementia risk, travel patterns are not considered a significant contributing factor to the overall prevalence of dementia.

E. Increased number of Americans attending college: There is no evidence to suggest a direct link between attending college and the prevalence of dementia. Educational attainment may have a protective effect against dementia, but it is not a factor driving the growing numbers of diagnoses in the United States.

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A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is caring for a group of clients with dementia. The nurse recognizes which of the following factors as reasons for the growing numbers of clients diagnosed with dementia in the United States? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

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