An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?
Document the client's loss of memory in the record.
Notify the family of the change in the client's condition.
Remind the client what day of the week it is.
Encourage the client to rest during the day.
The Correct Answer is C
it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
Correct Answer is A
Explanation
A) Correct- Electrolyte imbalances, particularly involving electrolytes like potassium, can lead to cardiac arrhythmias. Elevated blood pressure can strain the cardiovascular system, and mental status changes could indicate potential neurologic and cardiovascular involvement. Auscultating for an irregular heart rate helps identify any immediate cardiac issues that require intervention.
B) Incorrect- While monitoring sodium intake is important for clients with chronic kidney disease, it is not the most urgent action in this scenario. The presence of electrolyte imbalance, elevated blood pressure, and changes in mental status indicate a more acute concern that requires immediate assessment.
C) Incorrect- Documenting abdominal girth is relevant for assessing fluid status, but in this situation, the presence of electrolyte imbalance, elevated blood pressure, and mental status changes indicates a more critical issue that requires prompt intervention.
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