hard · NCLEX-RN management
An 81-year-old client with a history of mild neurocognitive disorder (dementia) is hospitalized for a severe urinary tract infection. At 0200, the client becomes agitated, pulls at their IV line, and insists on going home immediately, stating, 'I need to feed my dog.' The client's baseline is oriented to person and place. Which actions are appropriate for the registered nurse (RN) to take? Select all that apply.
- Administer a high-dose IV sedative immediately to chemically restrain the client so they cannot leave.
- Contact the provider and the client's designated surrogate decision-maker to discuss the client's acute mental status change and safety needs.
- Perform a focused assessment for acute delirium using a validated cognitive tool and check the client's oxygenation and glucose levels.
- Allow the client to leave immediately because they have a baseline diagnosis of dementia and possess the right to make their own decisions.
- Implement restraint-free safety measures, such as placing a bed alarm, reorienting the client with simple statements, and scheduling supervised toileting.
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