An older adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that the client was confused prior to admission. What action should the practical nurse (PN) take?
Document the client's loss of memory in the record.
Encourage the client to rest during the day.
Notify the family of the change in the client's condition.
Remind the client what day of the week it is.
The Correct Answer is D
A. Document the client's loss of memory in the record: While documentation is important, recording the symptom alone does not address the client’s immediate disorientation or provide support for orientation.
B. Encourage the client to rest during the day: Promoting rest can be helpful for overall cognitive function, but it does not directly assist the client in regaining orientation or managing confusion in the moment.
C. Notify the family of the change in the client's condition: Informing family may be appropriate if the confusion persists or worsens, but the first priority is to reorient and support the client in real time.
D. Remind the client what day of the week it is: Reorientation is the initial nursing intervention for acute confusion. Providing cues about time, place, and situation helps the client regain orientation and reduces anxiety associated with disorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Upper torso: In older adults, the center of gravity shifts upward toward the upper torso due to changes in posture, muscle mass, and spinal curvature. Recognizing this shift helps the PN use proper body mechanics and prevent falls or musculoskeletal injury when assisting the client.
B. Head: The head contributes to balance but is not the primary location of the center of gravity. Focusing on the head alone would not provide effective guidance for safe mobility assistance.
C. Upper extremities: While upper extremities are important for support and mobility, they do not represent the center of gravity. Relying on arm strength without adjusting posture could compromise safety.
D. Feet: Feet provide the base of support but are not the center of gravity. Proper positioning of the client’s torso and alignment is critical to maintain balance and prevent falls during transfers.
Correct Answer is C
Explanation
A. A 26-year-old client: Identifying the client is important but is not the most urgent information when using SBAR. It provides context but comes after the immediate concern.
B. Intravenous fluids infusing at 75 mL/hour: While IV fluids are relevant background information, they do not indicate the acute problem that requires immediate attention.
C. Blood pressure is 80/48 mmHg: In the SBAR framework, the “Situation” should include the most urgent and critical information. Hypotension is a potentially life-threatening finding that must be communicated first to prompt timely intervention.
D. Cholecystectomy 24 hours ago: Surgical history is part of the background information and provides context for the current situation, but it is secondary to the acute vital sign abnormality.
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