A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Orient the client to their surroundings.

Close the client's room door.

Escort the client back to the room.

Raise the four side rails on the bed.

Secure a bed alarm on the mattress.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.

Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.

Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.

Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.

Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.

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Correct Answer is D

Explanation

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

A. Fibromyalgia B. Peptic ulcer disease. C. Hypertension D. Hypothyroidism.

Correct Answer is C

Explanation

Choice A reason: Fibromyalgia is a chronic condition characterized by widespread pain, but it is not directly associated with obstructive sleep apnea.

Choice B reason: Peptic ulcer disease is not commonly linked to obstructive sleep apnea.

Choice C reason: Hypertension is a known complication of obstructive sleep apnea due to the recurrent episodes of low oxygen levels during sleep, which can lead to increased blood pressure.

Choice D reason: Hypothyroidism is a condition affecting the thyroid gland and is not typically a complication of obstructive sleep apnea.

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A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Correct Answer is D

Explanation

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

Correct Answer is C

Explanation

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?

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The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?