An elderly client was well until 12 hours ago, when she reported ...

[ss2343]

An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed.
 
  She admits to being very frightened. She is presently pacing and somewhat agitated in the ex-amining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
  1. Interact with the client on an adult to child level.
  2. Place the client in a safe, nonstimulating environment.
  3. Ask client why she thinks someone would be trying to frighten her.
  4. Explain to the family that the client will be restrained for her own good.

Question 2

A client diagnosed with Alzheimer's disease has a catastrophic reaction during an activity in-volving simultaneous playing of music and working on a craft project. The client starts shouting no, no, no and rushes out of the room. The nurse sho
 
  1. Isolate the client until she is calm, and then direct her back to the activity
  2. Follow the client, reassure her, and redirect her to a quieter activity
  3. Discontinue the activity program since it upsets the clients
  4. Give the client prn antianxiety medication and restrict her activity participation

[sierrahalpin]

Answer to Question 1

ANS: 2
The safety of a client with delirium is of primary importance. Symptoms of delirium fluctuate and may worsen, especially at night. The greater the client's confusion and disorientation, the greater the possibility for self-harm. Option 1 is demeaning. Option 3 is inappropriate, because delirious clients cannot formulate rational answers. Option 4 is inappropriate. Clients are never restrained unless less restrictive measures have failed.

Answer to Question 2

ANS: 2
These actions will restore safety and self-esteem. 1. Isolation will decrease self-esteem and may increase confusion. 3. It is only one client who is distressed. 4. Behavioral interventions should be attempted prior to administering medication.

[ss2343]

Thanks for the timely response, appreciate it

[shailee]

TYSM