An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

Administer a prescribed PRN benzodiazepine at the onset of a confused state.

Ensure that the client is assigned to a room close to the nurses' station.

Postpone administration of nighttime medications until after 2300.

Ask family members to remain with the client in the evenings from 1700 to 2000.

Answer and Explanation

The Correct Answer is B

A. Administering a PRN benzodiazepine is a reactive measure and might not be the best first line of intervention for managing the client's restlessness and confusion, as it does not address the underlying issue.
B. Assigning the client to a room close to the nurses' station can help manage restlessness, confusion, and agitation by ensuring the client is monitored more closely and can receive timely interventions.
C. Postponing nighttime medications might not address the immediate issues of restlessness and confusion, and could potentially disrupt the client's sleep-wake cycle.
D. Asking family members to stay with the client provides support but may not be a feasible or consistent solution for managing the client’s evening agitation and restlessness.

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Correct Answer is A, C, B, D

Explanation

A. Informing the client of the purpose of the medication is the first step. This action ensures that the client understands why they are receiving the medication and what it is intended to do.

C. Putting on a clean pair of gloves is the next step to maintain hygiene and prevent contamination while handling the medication and applying the patch.

B. Placing the patch on a new area of cleansed skin follows glove application. Ensuring that the skin is clean and that a new site is used prevents irritation and ensures the effectiveness of the medication.

D. Documenting the application in the electronic medication record is the final step to complete the medication administration process. This ensures that the medication administration is recorded accurately for future reference and compliance.

Correct Answer is []

Explanation

The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.

Actions to Take:

Use Therapeutic Communication to Build Rapport
Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction.
Teach Coping Skills
Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.

Parameters to Monitor:

Heart Rhythm
Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment.
Vital Signs
Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications

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An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In administering a nitroglycerin transdermal patch to a client with chronic angina pectoris, in which order should the practical nurse (PN) carry out the actions? (Arrange from first action on top to last on the bottom.)

Correct Answer is A, C, B, D

Explanation

Correct Answer is []

Explanation

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