Which of the following is a priority nursing intervention for the ...

[fahad]

Which of the following is a priority nursing intervention for the management of delirium?
 
  A) Giving the client low-dose oxygenation and maintaining his or her fluid and electrolyte balance
  B) Reducing noise and placing familiar objects in the client's environment
  C) Giving the client a clock, a watch, and calendars to provide the client with temporal orientation
  D) Providing psychological support through cognitive and social stimulation

Question 2

An older adult started an antidepressant 1 week ago. The client states, I don't want to take that pill, it's not doing anything. Which of the following responses by the nurse is most appropriate?
 
  A) That is fine, it is your right to refuse medications.
  B) It is too soon to see effects; positive effects may begin around 3 weeks.
  C) Let's notify the primary health care provider to try another type of medication.
  D) What side effects are you having?

[mcarey591]

Answer to Question 1

Ans: A
Priority questions address physiologic integrity. The client needs to be stabilized before the other interventions can be implemented.

Answer to Question 2

Ans: B
Immediate improvement will not be evident, but a fair trial must be given to the medication as long as serious adverse effects are not noticed. The fair trial may take as long as 12 weeks, but some positive effects should be noticed within 2 to 4 weeks. If one type of antidepressant is not effective, another type may be effective. The right to refusal is the seventh medication right; however, it is the nurses' responsibility to ensure that the client is informed before accepting the refusal.

[fahad]

Excellent

[chereeb]

TYSM