A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
Ask the client to state their room number.
Have the client state their phone number.
Request an assistive personnel to identify the client.
Review the client's photograph in the medical record.
The Correct Answer is D
Choice A Reason:
Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.
Choice B Reason:
Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.
Choice C Reason:
Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.
Choice D Reason:
Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A client who has ulcerative colitis is correct. Ulcerative colitis, a type of inflammatory bowel disease (IBD), involves chronic inflammation and ulceration in the colon and rectum. This condition often results in bleeding from the inflamed mucosa, leading to the presence of blood in the stool that can be detected by a fecal occult blood test.
Choice B Reason:
A client who has stomatitis is incorrect. Stomatitis refers to inflammation in the mouth and does not typically cause bleeding in the gastrointestinal tract, which is what the fecal occult blood test detects. Stomatitis involves oral lesions or sores but does not directly impact stool blood content.
Choice C Reason:
A client who uses laxatives is incorrect. Laxative use does not necessarily cause bleeding in the gastrointestinal tract. While some laxatives can potentially irritate the intestinal lining, leading to minor bleeding in some cases, the presence of blood in the stool due to laxative use is less common compared to conditions like ulcerative colitis, where chronic inflammation and ulceration lead to significant bleeding.
Choice D Reason:
A client who has cholecystitis is incorrect. Cholecystitis is inflammation of the gallbladder and does not directly involve bleeding in the gastrointestinal tract. It typically presents with symptoms related to gallbladder inflammation such as abdominal pain, nausea, and vomiting, rather than causing bleeding that would be detected by a fecal occult blood test.
Correct Answer is D
Explanation
Choice A Reason:
Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.
Choice B Reason:
Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.
Choice C Reason:
Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.
For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:
Choice D Reason:
Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.
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