Question

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. Document the information in the client's chart
B. Disregard the report as it may be inaccurate
C. Observe the client for signs of further agitation
D. Contact the healthcare provider for further orders

Answer 1

The day shift nurse should observe the client for signs of further agitation after receiving a report of disorientation and combativeness, document the behavior if it continues, and contact the healthcare provider for further orders if necessary.

Step-by-step explanation:

Upon receiving the report of a newly admitted client being disoriented and combative during the night, the day shift nurse should observe the client for signs of further agitation. This is crucial for ensuring the safety and well-being of the client as well as the staff. If the client exhibits signs of agitation or the behavior continues, the nurse may consider documenting the behavior in the client's chart, which is essential for continuity of care. Following the observation, contacting the healthcare provider for further orders may be necessary if the nurse believes the situation could lead to harm or requires medical intervention.