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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The client needs to have someone come in to help her bathe at home is incorrect. While this indicates a need for assistance with activities of daily living, such as bathing, it does not necessarily require the involvement of a social worker. This need may be addressed by home health aides or other community resources.
Choice B Reason:
The client needs to have range-of-motion exercises to assist with ambulation is incorrect. This suggests a need for rehabilitation or physical therapy services, which would typically be addressed by a physical therapist rather than a social worker.
Choice C Reason:
The client needs to arrange financial resources to purchase equipment is correct. The need to arrange financial resources indicates potential financial concerns or barriers that a social worker can assist with. Social workers are trained to help clients access resources and support services, including assistance with financial matters.
Choice D Reason:
The client needs to have someone bring oxygen tanks and equipment to her home is incorrect. While this indicates a need for assistance with arranging for medical equipment, such as oxygen tanks, it may be more closely related to coordination with home healthcare services or medical equipment providers rather than the role of a social worker.
Correct Answer is B
Explanation
Choice A Reason:
"The nurse verbalizes their understanding of the plan," is important, verbalizing understanding does not necessarily guarantee successful implementation of the plan. Action is required to demonstrate competence and improvement.
Choice B Reason:
The nurse performs all tasks as specified is correct. The effectiveness of a performance improvement plan is best determined by observing whether the nurse successfully implements the specified tasks and achieves the desired improvements in their performance. Therefore, option B, "The nurse performs all tasks as specified," is the most appropriate outcome to indicate the effectiveness of the plan.
Choice C Reason:
"The nurse attends a critical thinking class," may be a component of the performance improvement plan, but attending a class alone does not necessarily indicate whether the nurse's performance has improved.
Choice D Reason:
"The nurse shares their performance plan with another nurse," is not a direct measure of the effectiveness of the plan. Sharing the plan with another nurse may demonstrate openness and willingness to seek support, but it does not necessarily indicate whether the nurse has successfully improved their performance as a result of the plan.
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