An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to
a. give PRN lorazepam (Ativan) and cancel the transfer.
b. inform the receiving nurse and then transfer the patient.
c. notify the health care provider and postpone the transfer.
d. obtain an order for restraints as needed and transfer the patient.
ANS: B
The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.
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