The nurse has reviewed the nurses’ notes, provider’s note, and vital signs at 0400.
Nurses’ Notes 0205: Client brought to the ED by police after being found wandering on the street.
Client able to provide identity to police but not able to identify place or time.
Family notified.
0230: Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry.
Lungs clear and equal, heart rhythm regular.
During data collection, the client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.
The client’s adult child arrived at the ED and went to the client’s room.
The client identified the family member.
The client is pacing and agitated and states, “I don’t understand why I am here.”. The adult child asks the nurse to talk outside of the room and states, “I don’t know why they are so confused.
They are not normally like this.”. The adult child states the client has a past medical history of hypertension and.
For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
Potential Provider Prescription: . Administer acyclovir.
Administer lorazepam.
Initiate 1:1 supervision.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
Expected . Unexpected.
The Correct Answer and Explanation is:
Potential Provider Prescription:
- Administer acyclovir – Unexpected
- Administer lorazepam – Expected
- Initiate 1:1 supervision – Expected
- Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion – Expected
Explanation:
- Administer acyclovir (Unexpected): Acyclovir is an antiviral medication used to treat viral infections such as herpes simplex, varicella-zoster, and shingles. In the context of this client’s presentation, there is no indication of a viral infection that would warrant the use of acyclovir. The client’s symptoms, such as confusion, agitation, and hallucinations, suggest a mental status change or delirium rather than an infectious process that requires antiviral treatment.
- Administer lorazepam (Expected): Lorazepam is a benzodiazepine commonly used for its anxiolytic, sedative, and anticonvulsant properties. The client is exhibiting agitation, pacing, and confusion, which are common in states of acute delirium, anxiety, or psychosis. Lorazepam can help to calm the client, reduce agitation, and prevent further escalation of distress. Additionally, if alcohol withdrawal is suspected, lorazepam could help manage withdrawal symptoms. Therefore, this prescription is expected given the client’s current state.
- Initiate 1:1 supervision (Expected): The client is confused, disoriented, agitated, and experiencing visual hallucinations (pointing to an empty chair). These symptoms raise concern for the client’s safety, as they may pose a risk of wandering, falling, or acting unpredictably. Initiating 1:1 supervision is a standard intervention in such cases to ensure the client’s safety and prevent harm. This supervision allows healthcare staff to monitor the client closely and intervene immediately if necessary.
- Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion (Expected): The client has dry mucous membranes, which is a sign of dehydration. Administering isotonic fluids, such as 0.9% sodium chloride, helps to correct dehydration, maintain fluid balance, and prevent complications such as electrolyte imbalances. Dehydration could also be contributing to the client’s confusion, making this intervention appropriate to improve the client’s hydration status and overall condition.
In conclusion, acyclovir is unexpected due to the lack of an infectious process requiring antiviral therapy. The other interventions (lorazepam, 1:1 supervision, and IV fluids) are expected and align with the client’s symptoms of agitation, confusion, and dehydration.