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During the 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. Administer a sedative medication
B. Document the findings and monitor the client
C. Call the healthcare provider for a psychiatric consult
D. Restrict the client to bed for safety

User Lizza
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Final answer:

The day shift nurse should document the findings and monitor the newly admitted client who was disoriented and combative, as informed by the night shift nurse. The nurse should observe closely to evaluate the situation correctly before considering further action.

Step-by-step explanation:

During the change of shift report, when a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night, the day shift nurse should prioritize understanding the situation and ensuring patient safety. The appropriate action for the day shift nurse to take would be to document the findings and monitor the client (Option B). It is important to observe the client's behavior and mental status closely to determine if the situation was an isolated incident or indicative of an underlying condition that requires additional intervention. Sedation (Option A) should not be administered without assessing the client and without a doctor's order. Calling for a psychiatric consult (Option C) might be premature without further assessment. Restricting the client to bed (Option D) may not be necessary and could escalate the situation if the client does not understand the reason for the restriction.

A nurse must also ensure that communication between healthcare professionals, such as during shift changes, includes a review of the key concerns for the recovery and care of the patient, including any changes in behavior or mental status.

User Purres
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