Author Question: A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to ... (Read 40 times)

burchfield96 · **on:** Jul 19, 2018

A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse.

His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
1. Take the client's vital signs
2. Restrain the client to prevent injury
3. Obtain a prn order for a psychotropic medication
4. Ask the client for information about his medications

Question 2

The caregiver for a client with moderate to severe dementia tells the nurse, I'm exhausted. He wanders at night instead of sleeping, so I get no rest.

I'm afraid to leave him during the day, so I have to take him to the grocery store and to the laundromat. When I'm busy there, he often wanders off. Still, I have to do it all. The nurse rec-ognizes the need to provide teaching for this caregiver. An appropriate outcome is that the care-giver will:
1. Feel justified in putting the client in a nursing home
2. Verbalize realistic self-expectations
3. Cease abusive interactions with the client
4. Feel comfortable leaving the client alone one morning a week

javimendoza7 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: 1
The disorder may be due to an infection or underlying organic disorder, so vital signs are of first priority. Restraint is not indicated at this time, nor is medication. Option 4 is incorrect because the client is confused and disoriented.

Answer to Question 2

ANS: 2
A desired outcome would be for the caregiver to come to understand that she is expecting too much of herself by trying to be available to the client 24 hours a day. Once the client realizes she cannot do it all, she will be more open to using community support services. 1. This may not be necessary. 3. This is inappropriate; no evidence of abuse exists. 4. This would be inappropriate at the client's stage of dementia.