An older adult client of a long-term care facility is awake at 0330 and wandering down the hall in unbuttoned pajamas. Which intervention should the practical nurse (PN) implement?
Bring the client to sit in the nursing station.
Administer a nighttime sedative.
Direct the client to go back to bed.
Engage the client to determine current needs.
The Correct Answer is D
A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Move away from the overbed table: This action can be done after the gloves are completely removed and disposed of. Moving away too early increases the risk of bumping into something and contaminating the gloves.
B. Sterile gloves are contaminated on the outside after performing a procedure like a dressing change. Pulling the glove down and everting it (turning it inside out) confines the contamination to the inside of the glove, reducing the risk of transferring germs to the hands or surrounding surfaces. This maintains a sterile field and minimizes the risk of healthcare-associated infections (HAIs).
C. Loosen the glove from the fingers: This might be the initial step while grasping the glove for removal, but the key is to maintain aseptic technique by keeping the outside of the glove contained throughout removal.
D. Raise the hands above waist level: Raising hands above the waist level increases the risk of contaminating the sterile field or nearby surfaces if the glove integrity is compromised.
Correct Answer is D
Explanation
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
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