A client admitted for treatment of trauma sustained in a fall while intoxicated believes bugs are
crawling on the bed. The client is anxious, agitated, and diaphoretic.
While the client is experiencing
sensory perceptual disturbances and clouded sensorium, the nursing intervention that should be
instituted is
a. checking the client every 15 minutes.
b. providing one-on-one supervision.
c. keeping the room dimly lit.
d. rigorously encouraging fluid intake.
B
One-on-one supervision will be necessary to promote physical safety until sedation reduces the
client's feelings of terror. Option A: Checks every 15 minutes would not be sufficient to provide for
safety. Option C: A dimly lit room promotes illusions. Option D: Excessive fluid intake can cause
overhydration because fluid retention normally occurs when blood alcohol levels fall.
You might also like to view...
There are four principles inherent in the concept of whole-systems shared governance. Which of these principles are noted below? Select all that apply
a. partnership c. accountability b. collaboration d. ownership
Before performing a blood glucose test using a glucometer, the nurse asks the client if he has ever had his blood glucose level measured using a glucometer before
Which of the following statements is a possible reason for the nurse to ask this question? A) Provides a basis for teaching B) Aids in reducing blood glucose levels C) Determines whether test strips are appropriate for use D) Ensures that the test is accurate
Nurse executives are asked to play important roles in the shaping of HIT policy. Which of the following apply to ways in which they can be actively involved? Select all that apply
1. Overcome financial and cultural barriers related to HIT 2. Support and provide leadership development on HIT-related topics 3. Incrementally decrease the information technology budget line for support services 4. Contribute to research that substantiates the business case for nursing 5. Improve patient safety through the use of decision-support tools at the point of care
A resident cannot speak or read. To communicate with the person, you should:
a. Follow the person's care plan b. Shout slowly and distinctly c. Use sign language d. Use body language