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 A
Explanation
A. This activity addresses both physical and social needs. It provides a gentle physical activity that can be enjoyed by people with limited mobility. It also encourages social interaction and teamwork, promoting a sense of belonging and camaraderie.
B. An open-air concert is enjoyable but may not fully engage residents in both physical and social aspects. While it offers entertainment, it lacks interactive elements that foster social engagement and physical involvement.
C. This activity requires more mobility than wheelchair-bound residents may have, especially if it involves walking on uneven terrain or sitting on the ground.
D. A tea party in the courtyard is a social activity but does not offer as much physical engagement or variety as a picnic in the park. While it is a pleasant option, it may not provide the same level of physical stimulation and change of scenery.
Correct Answer is ["A","C","D"]
Explanation
A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.
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