Author Question: A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she ... (Read 109 times)

jeatrice · **on:** Jul 11, 2018

A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she had outpatient cataract surgery.

The patient who lives in an assisted living facility became very confused and agitated and was found wandering in the lobby of the building in her nightgown. She refused to return to her room and stated that there were bad men in her room. The patient has a history of dementia, diabe-tes, heart failure, and is on seven different medications. She was widowed 1 year ago. The nurse suspects that she has delirium. What are the patient's risk factors for delirium? (Select all that ap-ply.)
a. Age of 92
b. Residing in an assisted living facility
c. History of dementia
d. Female gender
e. Recent cataract surgery

Question 2

Which intervention to manage wandering in clients in a long-term care facility should be imple-mented? (Select all that apply.)

a. Camouflaging doorways
b. Close observation to identify the person's individual patterns
c. Engaging the person in social interactions
d. Using physical restraints to prevent wan-dering to maintain safety
e. Providing enclosed pathways for walking

livaneabi · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: A, C, E
This patient's risk factors for delirium include her older age, history of dementia, and recent sur-gery. There is no evidence that living in an assisted living facility or being female increase risk of delirium.

Answer to Question 2

ANS: A, B, C, E
Restraints are not an effective intervention for wandering. Although they might physically pre-vent the person from wandering, restraints have many potential negative consequences and pa-tient harm associated with their use. Environmental modifications such as camouflaging door-ways and providing enclosed pathways, close observation to identify the person's individual patterns, and engaging the person in social interactions are all interventions that are effective strategies to manage wandering.