Difficulty: Medium
Average Score: 94%
Simulated
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)
Correct answer
A,B,C
Rationale
A calm demeanor, reorientation, and lorazepam address anxiety and hallucinations effectively. Television may worsen symptoms, and restraints are a last resort.