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 B

Explanation

A. Lower extremities edematous with decreased pulses and cool to the touch While this finding suggests impaired circulation associated with peripheral artery disease, it does not indicate an immediate need for intervention. However, it requires timely assessment and intervention to prevent further complications.

B. Pain, pallor, and paresthesia in the foot This finding indicates critical limb ischemia, which is a severe complication of peripheral artery disease requiring immediate intervention. Pain, pallor (pale color), and paresthesia (abnormal sensations like tingling or numbness) suggest inadequate blood flow to the affected limb, putting the client at risk for tissue damage and limb loss if not promptly addressed.

C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema These findings are suggestive of cardiac issues such as heart failure rather than immediate complications of peripheral artery disease. While they require attention, they do not signify an urgent need for intervention specific to peripheral artery disease.

D. Presence of an open wound near the ankle with serous drainage and pruritus While an open wound warrants assessment and appropriate wound care, it does not indicate an immediate need for intervention unless there are signs of infection or severe tissue damage. In this scenario, the presentation of pain, pallor, and paresthesia indicates a more urgent need for intervention to prevent tissue necrosis and limb loss.

A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration B. A decrease in heart rate greater than 10/min when lying down C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration D. An increase in heart rate greater than 20/min when standing

Correct Answer is A

Explanation

A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration: Pulsus paradoxus is an exaggerated decrease in systolic blood pressure during inspiration. Normally, there is a slight decrease in systolic blood pressure during inspiration due to increased intrathoracic pressure and decreased venous return to the heart. However, in conditions such as cardiac tamponade or severe asthma exacerbations, the decrease in systolic blood pressure during inspiration is more pronounced (>10 mm Hg), indicating impaired cardiac output and decreased left ventricular filling during inspiration.

B. A decrease in heart rate greater than 10/min when lying down: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when lying down.

C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus is characterized by an exaggerated decrease in systolic blood pressure during inspiration, not changes in diastolic blood pressure.

D. An increase in heart rate greater than 20/min when standing: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when standing.

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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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Correct Answer is B

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Correct Answer is A

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