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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and skills. This task should be performed by a licensed nurse to ensure accurate instruction and patient understanding.
B. Irrigating an indwelling urinary catheter involves sterile technique and specialized knowledge, which should be performed by a licensed nurse. This task requires specific training to prevent complications.
C. Transporting a urine culture sample to the laboratory can be safely assigned to a UAP. It involves routine tasks that do not require advanced clinical skills and is essential for timely processing of specimens.
D. Emptying the bedside drainage unit for a client with an indwelling urinary catheter can be performed by a UAP. This task involves basic care procedures that support patient hygiene and comfort.
E. Obtaining a post-voided residual (PVR) volume requires a specific clinical skill and understanding of the procedure, which should be performed by a licensed nurse rather than a UAP.
Correct Answer is D
Explanation
A. Missing the child every day is a normal part of the grieving process but does not indicate improvement in managing depression.
B. Drinking 4 to 6 bottles of beer each evening suggests the client may be using alcohol as a coping mechanism, indicating poor management of depression.
C. Expressing that drunk driving is inexcusable shows the client has a strong opinion on the matter, but it does not necessarily indicate improvement in the client’s emotional health.
D. Sleeping through the night often indicates an improvement in the client’s ability to rest and manage depressive symptoms, suggesting a positive response to treatment.
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