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. Monitor the client for nausea or vomiting following the treatment: Ondansetron is an antiemetic used to prevent or reduce chemotherapy-induced nausea and vomiting. Evaluating its effectiveness involves assessing whether the client experiences these specific symptoms during and after treatment.
B. Observe the client for signs of pain or discomfort during the treatment: While monitoring for pain is important, ondansetron does not address pain. Observing pain does not provide information about the effectiveness of this antiemetic.
C. Assess for changes in vital signs during and after the treatment: Vital signs may be influenced by chemotherapy or other medications, but they are not a reliable measure of ondansetron’s effectiveness in controlling nausea and vomiting.
D. Determine if the client feels calm and relaxed before the treatment: Ondansetron does not have anxiolytic properties. Evaluating the client’s emotional state before treatment does not assess the effectiveness of the medication in preventing nausea or vomiting.
Correct Answer is C
Explanation
A. Ensure that the client's arm remains elevated after the blood pressure is recorded: Elevation of the operative arm is important for comfort and edema prevention, but it does not address the risk of lymphedema caused by applying a blood pressure cuff to the surgical side.
B. Review the client's blood pressure as soon as the UAP records the measurement: Reviewing the reading does not prevent potential harm to the operative arm. The priority is preventing injury or complications before the measurement is taken.
C. Instruct the UAP to measure the client's blood pressure on the non-operative side: Blood pressure should never be measured on the side of a mastectomy because cuff pressure can increase the risk of lymphedema and impair healing. Directing the UAP to use the non-operative arm protects the client and follows best practice guidelines.
D. Advise the UAP to use a manual blood pressure cuff for a more accurate reading: Accuracy is not the issue in this situation; the priority is preventing trauma to the operative arm. Using a manual cuff on the surgical side still poses a risk.
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