A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?
Obtain a prescription for a sedative for the client.
Remove the clock and calendar from the client's room.
Provide distractions for the client during the day.
Raise all four side rails on the client's bed.
The Correct Answer is C
Choice A reason: Obtaining a prescription for a sedative for the client is not a correct action, as it may cause adverse effects such as confusion, falls, or respiratory depression. The nurse should avoid using sedatives unless absolutely necessary and use non-pharmacological interventions to calm the client.
Choice B reason: Removing the clock and calendar from the client's room is not a correct action, as it may worsen the client's disorientation and anxiety. The nurse should provide orientation cues such as a clock, a calendar, a radio, or a newspaper to help the client maintain a sense of time and reality.
Choice C reason: Providing distractions for the client during the day is a correct action, as it may reduce the client's boredom, agitation, and wandering behavior. The nurse should engage the client in meaningful activities such as music, games, crafts, or exercise that suit the client's interests and abilities.
Choice D reason: Raising all four side rails on the client's bed is not a correct action, as it may increase the risk of injury or entrapment if the client tries to climb over them. The nurse should use the least restrictive measures to prevent wandering, such as alarms, locks, or supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because this action is not legally required or ethically appropriate. The client has the right to refuse treatment and leave the hospital at any time, as long as she is competent and informed of the risks and consequences. The nurse should not coerce or threaten the client to stay against her will.
Choice B reason: This is not the correct choice because this action is not helpful or respectful. The client may have valid reasons for wanting to go home, such as personal or financial issues. The nurse should not assume that the client is anxious or irrational and offer her a sedative, which may impair her judgment and consent.
Choice C reason: This is not the correct choice because this action is not necessary or professional. The client is not a threat to herself or others, and does not need to be restrained or guarded by a security officer. The nurse should not use intimidation or force to prevent the client from leaving.
Choice D reason: This is the correct choice because this action is the best practice and the standard procedure. The nurse should explain to the client the benefits of staying and the risks of leaving, and document the conversation. The nurse should also ask the client to sign the Against Medical Advice form, which states that the client understands the implications of her decision and releases the hospital and the provider from liability.
Correct Answer is A
Explanation
Choice A reason: A client who had a recent stroke and is showing manifestations of depression needs an interdisciplinary conference because they require a comprehensive and coordinated plan of care that involves multiple disciplines, such as physical therapy, occupational therapy, speech therapy, social work, and mental health services.
Choice B reason: A client whose provider is unhappy with the nursing care does not need an interdisciplinary conference, but rather a feedback and evaluation session with the nurse manager and the provider to address the issues and improve the quality of care.
Choice C reason: A client whose MRI results have not been made available after 2 days does not need an interdisciplinary conference, but rather a follow-up with the radiology department and the provider to expedite the results and adjust the treatment plan accordingly.
Choice D reason: A client whose partner requests that the client be moved to a private room does not need an interdisciplinary conference, but rather a discussion with the admission office and the partner to explore the availability and cost of a private room and the benefits and risks of transferring the client.
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