A long-term care resident is taking an anticholinergic agent. The nurse observes the resident to be disoriented and hallucinating. The priority nursing action is to
a. report development of alterations to the charge nurse.
b. assess blood glucose.
c. provide for resident's safety.
d. medicate with antianxiety medication.
ANS: C
Serious psychological side effects of anticholinergic agents include confusion, depression, nightmares, and hallucinations. The priority nursing action at onset of confusion and hallucinations is safety. Once the resident is safe, development of alterations may be reported. Blood glucose may be monitored once safety is established. If appropriate medications are ordered by the physician, they can be provided once the resident is calm and safe.
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