A intensive care nurse cares for an 83-year-old with sepsis. The client exhibits illogical thinking and agitation. Which intervention should the nurse implement? (Select all that apply.)
A) Administer a benzodiazepine.
B) Assess for pain.
C) Assure a quiet, dark sleep time.
D) Initiate fall prevention program.
E) Post pictures of client's family in room.
Ans: B, C, D, E
Older clients with infection and those in the ICU are at great risk for delirium. Sleep, rest, pain control, and familiar items are interventions to minimize delirium. The client is a greater risk for falls so a fall prevention program should be initiated. Benzodiazepines should be avoided.
You might also like to view...
The nurse is caring for a patient who is unable to swallow properly. What drug would the nurse expect to be prescribed?
A) Apomorphine (Apokyn) B) Bromocriptine (Parlodel) C) Levodopa (Dopar) D) Ropinirole (Requip)
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply
A) Administering diuretics B) Administering calcium channel blockers C) Implementing fluid restrictions D) Implementing a 1500 kcal/day restriction E) Enhancing patient positioning
Which of the following is the most important question to ask during cardiovascular health history?
A. Number of offspring B. Last physical examination C. Sudden death of a family member D. Use of caffeine
At birth, a premature infant has a hemoglobin of 9.5, has a pulse of 180, and appears pale. What other laboratory results would be most important for the nurse to review?
a. Bilirubin level c. Direct and indirect Coombs' test b. Platelet count d. Glucose