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

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta: This statement is incorrect. Abdominal aortic aneurysms (AAAs) are most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal region.

B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery: This statement is incorrect. An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm.

C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter: This statement is correct. An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition.

D. Abdominal aortic aneurysms might rupture if blood pressure is too low: This statement is incorrect. Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture.

A. Varicose veins B. Heart murmur C. Palpitations D. Abdominal pain E. Chest pain

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

Explanation

A. Varicose veins: Varicose veins are dilated, twisted veins that commonly occur in the legs and are typically associated with venous insufficiency or venous valve dysfunction rather than valvular dysfunction of the heart.

B. Heart murmur: This is the correct answer. Valvular dysfunction can result in abnormal blood flow patterns across the heart valves, leading to turbulent blood flow and the production of audible heart murmurs upon auscultation.

C. Palpitations: Palpitations, or the sensation of rapid, pounding, or irregular heartbeats, can occur with valvular dysfunction, particularly if the dysfunction leads to alterations in heart rhythm or cardiac output.

D. Abdominal pain: Abdominal pain is not typically associated with valvular dysfunction. It may be a symptom of various gastrointestinal or abdominal conditions, but it is not a direct manifestation of valvular heart disease.

E. Chest pain: This is the correct answer. Chest pain can occur with valvular dysfunction, especially if the dysfunction leads to inadequate blood flow to the heart muscle (ischemia), which can cause angina or chest discomfort.

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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?

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Naxlex Comprehensive Predictor Exams

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