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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A Reason:
Stating that the facility is unable to release the records, may not be accurate. Facilities typically have processes in place for releasing medical records upon request, although they may require written authorization.
Choice B Reason:
"You must submit a written request before you can receive a copy." This statement is correct. In most healthcare facilities, patients are required to submit a written request to obtain copies of their medical records. This process ensures that proper documentation is maintained and helps protect patient confidentiality and privacy. Additionally, providing medical records without proper authorization could violate healthcare privacy laws such as HIPAA (Health Insurance Portability and Accountability Act).
Choice C Reason:
Asking about the client's intentions with the medical record, is not appropriate as it could be seen as intrusive. Patients have the right to access their medical records for various purposes, and their intentions may not be relevant to fulfilling the request.
Choice D Reason:
Agreeing to make a copy of the medical records right away, is not the correct response without proper authorization. Making copies of medical records without following established procedures could lead to legal and ethical issues.

A. "A provider can write a prescription for restraints 'as needed"." B. "I should tie the restraints using a square knot." C. "I need to tie the restraint to the part of the bed frame that moves." D. "I will remove a client's restraints every 4 hours."

Correct Answer is B

Explanation

Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot.When applying restraints, using a square knot isessential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requests a copy of their medical records immediately. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

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