a nurse is caring for an older adult client with delirium which intervention will most effectively reduce the clients risk for falls
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

2. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?

Correct answer: A

Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.

3. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: The correct intervention for a client experiencing alcohol withdrawal is to administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to manage the symptoms of alcohol withdrawal by preventing seizures and reducing agitation and anxiety. Encouraging frequent ambulation (choice A) may not be safe during alcohol withdrawal due to potential instability and confusion. Providing a low-calorie diet (choice C) is not a priority during alcohol withdrawal, as the focus is on managing withdrawal symptoms. Administering insulin as prescribed (choice D) is unrelated to managing alcohol withdrawal symptoms.

4. A nurse is providing discharge teaching for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for complications?

Correct answer: C

Rationale: The correct answer is C. Suppression of the urge to defecate postoperatively can lead to complications such as constipation, which can increase the risk of complications after abdominal surgery. Walking twice daily (choice A) is actually beneficial for preventing complications such as deep vein thrombosis. Suppression of the urge to cough (choice B) can lead to issues like atelectasis. Lack of ambulation (choice D) can also contribute to complications like pneumonia and blood clots.

5. A client is recovering from an acute myocardial infarction. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct answer is to obtain a cardiac rehabilitation consult. Cardiac rehabilitation is an essential part of the care plan for a client recovering from a myocardial infarction. It helps in improving recovery, enhancing quality of life, and reducing the risk of future cardiac events. Drawing troponin levels and performing EKGs are important for diagnosing and monitoring myocardial infarctions but are not interventions in the post-MI care plan. Oxygen therapy may be necessary based on the client's condition but is not specific to post-MI care.

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