During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
A.
Keep the client’s television on with the volume low
B.
Insert an indwelling urinary catheter to minimize interaction with the client.
C.
Consult the provider regarding administering a mild sedative on a schedule.
D.
Move the client to a room near the nurses’ station
The Correct Answer and Explanation is:
The correct answer is D. Move the client to a room near the nurses’ station.
Explanation:
Rationale for Answer D:
Moving the client to a room near the nurses’ station is a prudent action when dealing with a disoriented and combative patient. This measure provides several benefits:
- Enhanced Monitoring and Safety: Placing the client closer to the nurses’ station ensures that the patient can be monitored more frequently and effectively. This is crucial for ensuring the patient’s safety, particularly if they are disoriented and at risk of wandering or accidental self-harm.
- Immediate Assistance: In case the patient becomes more agitated or combative, having them near the nurses’ station allows for quicker intervention by the nursing staff. This can help de-escalate the situation more promptly and effectively.
- Observation and Assessment: Proximity to the nurses’ station allows staff to observe the patient’s behavior and condition more closely, which aids in assessing whether there are any changes or worsening of the patient’s state.
Why Other Options Are Less Appropriate:
- Option A (Keep the client’s television on with the volume low): While having a television on might provide some distraction, it does not address the underlying issue of disorientation and combativeness. Moreover, it may not effectively prevent the client from becoming more agitated, and could potentially exacerbate the situation depending on the client’s preferences or mental state.
- Option B (Insert an indwelling urinary catheter): Using an indwelling catheter is an invasive procedure that does not address the root cause of the client’s disorientation and combativeness. It could also cause discomfort or lead to complications such as infections, and it does not address the need for careful monitoring and interaction.
- Option C (Consult the provider regarding administering a mild sedative on a schedule): Administering a sedative might be considered if the patient’s condition is not improving with other interventions. However, it should not be the first step. Medication adjustments should be guided by a thorough assessment of the patient’s needs and condition, and should be a part of a broader care plan that includes environmental and behavioral interventions.
In summary, moving the client closer to the nurses’ station provides immediate, practical benefits for monitoring and managing a disoriented and combative patient, making it the most appropriate action in this situation.