An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?
Document the client's loss of memory in the record.
Remind the client what day of the week it is.
Notify the family of the change in the client's condition.
Encourage the client to rest during the day.
The Correct Answer is B
A. Documenting the client's loss of memory is important for ongoing assessment, but it is not the immediate action to take when the client is confused about the day of the week.
B. Reminding the client of the day of the week is a direct intervention to help orient the client, which is a primary approach for managing acute confusion or disorientation.
C. Notifying the family of the change in the client’s condition may be necessary if confusion persists or worsens, but initial steps should focus on immediate management of the confusion.
D. Encouraging the client to rest is a general supportive action but does not address the specific issue of confusion about the day of the week.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.
Correct Answer is B
Explanation
A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.
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