A practical nurse (PN) is caring for clients on a locked Alzheimer's unit. Which client situation requires the PN's immediate attention?
Move the client who is knocking on the exit door and trying to get out.
Remind a confused client of today's date and the time lunch will be served.
Talk to a client who is wandering the halls looking in everyone's room.
Assist a client who is lying on the dayroom floor to sit in the chair.
The Correct Answer is D
A. Move the client who is knocking on the exit door and trying to get out: While this client’s behavior requires supervision to prevent elopement, there is no immediate physical harm, so it is not the highest priority.
B. Remind a confused client of today's date and the time lunch will be served: Reorientation is important for cognitive support, but it does not involve immediate risk of injury.
C. Talk to a client who is wandering the halls looking in everyone's room: Wandering poses some safety risks, but unless the client is in immediate danger, it is not as urgent as assisting a client on the floor.
D. Assist a client who is lying on the dayroom floor to sit in the chair: A client lying on the floor may have fallen and could have injuries or be at risk for further harm. Immediate attention is needed to assess for injury, prevent complications, and provide safe positioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tinnitus and vertigo after taking an aminoglycoside antiinfective: These are signs of ototoxicity, which are serious but typically develop after repeated dosing rather than immediately. Monitoring and reporting are important, but urgent intervention is less critical than acute hypersensitivity reactions.
B. Pruritus and urticaria after receiving a broad-spectrum antibiotic: These symptoms suggest an allergic reaction, which can progress rapidly to anaphylaxis. Immediate assessment, discontinuation of the drug, and notification of the healthcare provider are critical to prevent life-threatening complications.
C. Restlessness and excitability after receiving a narcotic analgesic: Mild restlessness can occur as a side effect, but it is usually not life-threatening. Continuous monitoring is appropriate, but it does not require the same immediate action as an allergic reaction.
D. Orthostatic hypotension and bradycardia after taking a beta blocker: These are known effects of beta blockers and should be monitored. While they may require intervention if severe, they are typically predictable and not immediately life-threatening compared to acute allergic responses.
Correct Answer is B,C,A,D
Explanation
A. Evaluate the UAP for signs of improvement: Following the teaching and feedback, the PN should observe the UAP’s future care interactions to ensure that the behavior has improved and that client privacy is consistently maintained.
B. Cover the client to provide privacy during care: The first priority is to protect the client’s dignity and privacy immediately. Ensuring the client is covered prevents further embarrassment and maintains ethical nursing standards.
C. Discuss the issue privately with the UAP: After addressing the client’s immediate needs, the PN should privately discuss the observed behavior with the UAP to promote learning and prevent public criticism, which can be unprofessional and counterproductive.
D. Report patterns of behavior to the supervisor: If the UAP repeatedly fails to uphold privacy standards despite feedback and monitoring, the PN must report the ongoing issue to the supervisor for further evaluation and possible corrective action.
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