Aclient with laënnec cirrhosis has a sengstaken-blakemore tube in place. the client becomes increasingly confused and tries to climb out of bed. the client's breath becomes fetid. what is the nursing priority

The answer would be: Apply a safety jacket

Patient with cirrhosis has a high level of toxins that will cause encephalopathy. The patient confused state probably caused by the encephalopathy. The confusion could make the patient hurt himself.
The priority should be to protect the patient. Using sedative is not recommended as it masks other symptoms.

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