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. Muscular aches in the leg: Muscular aches in the leg are not typically indicative of an impending cardiac arrest. While leg pain or cramping can be associated with peripheral vascular disease or venous insufficiency, they are not specific signs of cardiac arrest.

B. Profound fatigue: Profound fatigue can be a warning sign of an impending cardiac arrest. Fatigue or weakness can result from inadequate blood flow to the heart muscle, which may occur prior to a cardiac event. Additionally, systemic effects of cardiovascular compromise can lead to generalized weakness and fatigue.

C. Severe headache: While severe headache can be associated with conditions such as hypertension or intracranial bleeding, it is not a typical manifestation of an impending cardiac arrest. Headaches may occur as a result of stress or anxiety related to the cardiac event, but they are not a direct warning sign of impending cardiac arrest.

D. Ringing in the ears: Ringing in the ears, also known as tinnitus, is not typically associated with an impending cardiac arrest. Tinnitus can result from various factors such as noise exposure, ear infections, or certain medications, but it is not considered a warning sign of impending cardiac arrest.

A. Confusion B. Distress C. Agitation D. Depression E. Distraction

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

Explanation

A. Confusion: Individuals with Alzheimer's disease often experience confusion due to memory loss, disorientation, and difficulty processing information. Confusion can contribute to wandering behavior as the individual may become lost or disoriented in familiar surroundings, leading them to wander in search of familiar people or places.

C. Agitation: Agitation, characterized by restlessness, pacing, or irritability, is commonly observed in individuals with Alzheimer's disease. Agitation can be triggered by various factors such as environmental stimuli, changes in routine, or unmet needs. It can escalate and prompt wandering behavior as the individual seeks to alleviate discomfort or agitation.

E. Distraction: Individuals with Alzheimer's disease may easily become distracted by environmental stimuli or sensory cues, which can lead to wandering behavior. Distraction can impair the individual's ability to maintain attention to their surroundings, increasing the likelihood of wandering episodes.

The following options are not directly associated with wandering behavior in individuals with Alzheimer's disease:

B. Distress: While distress may be experienced by individuals with Alzheimer's disease due to various factors such as confusion, agitation, or environmental changes, it is not a specific manifestation that puts the client at risk for wandering. Distress may exacerbate wandering behavior in some cases but is not a primary risk factor.

D. Depression: Depression is a common comorbidity in individuals with Alzheimer's disease and can contribute to overall behavioral changes and functional decline. However, depression alone is not a direct manifestation that puts the client at risk for wandering. Wandering behavior is more closely associated with cognitive impairment, agitation, and environmental factors rather than depression.

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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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