A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?
Medicate the client with alprazolam.
Reorient the client to his surroundings.
Measure the client's vital signs.
Offer reassurance to the family.
The Correct Answer is C
Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Reinforcing dietary teaching with a client who has heart disease is incorrect. Dietary teaching typically requires a higher level of assessment and critical thinking, often involving interpretation of lab values, medication interactions, and individualized dietary plans. This task is best suited for a Registered Nurse (RN).
Choice B Reason:
Providing postmortem care for a client who has just died is incorrect. Providing postmortem care involves emotional support, respect for the deceased, and proper handling of the body. This task is within the scope of practice for an RN and may also involve collaboration with other healthcare team members.
Choice C Reason:
Accompanying a client who just had a wound debridement to physical therapy is incorrect. Accompanying a client to physical therapy may involve monitoring the client's condition, providing assistance during the transfer, and communicating with the physical therapist about the client's status. This task typically requires an RN or may be appropriate for an assistive personnel under RN supervision.
Choice D Reason:
Obtaining a urine specimen from an older adult client is correct. Obtaining a urine specimen is a task that falls within the scope of practice for an LPN. It involves performing a routine procedure that requires technical skills but does not involve complex assessment or critical thinking beyond following established protocols.
Correct Answer is B
Explanation
Choice A Reason:
Telling the client to leave her purse in a drawer of the bedside table is incorrect. Leaving the purse unattended in a bedside table drawer may not ensure its safety, as there could still be a risk of theft. Additionally, leaving valuables unattended in a hospital room may not be the safest option.
Choice B Reason:
Offering to place the purse in the facility safe is correct. Placing the purse in the facility safe is a secure option for safeguarding the client's belongings during surgery. It provides reassurance to the client that her valuables will be protected while she undergoes the procedure.
Choice C Reason:
Offering to store the purse at the nurses' station is incorrect. While storing the purse at the nurses' station may be a better option than leaving it in the client's room, it may not provide the same level of security as placing it in the facility safe. The nurses' station may be a busy area with various staff members coming and going, increasing the risk of theft.
Choice D Reason:
Placing the purse in the clothing bag with the client's other belongings is incorrect. Placing the purse in the clothing bag with the client's other belongings may not offer sufficient security, as the bag could still be accessible to unauthorized individuals. It's important to provide a secure storage option, such as the facility safe, to minimize the risk of theft.
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