An older female 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 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
This is the best action for the PN to take because 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.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C. Soft blanket.
Choice A rationale:
A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.
Choice B rationale:
The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.
Choice C rationale:
The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.
Choice D rationale:
Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.
Correct Answer is ["A","C","D"]
Explanation
The correct answers are:
A. Oatmeal is a good choice for breakfast.
C. Add lentils and black beans to soups.
D. Increase green leafy vegetables in the diet. Choice A rationale:
Oatmeal is a good choice for breakfast because it is a vegetarian option that is rich in iron. It contains non-heme iron, which is the type of iron found in plant-based foods. Non-heme iron may not be as easily absorbed as heme iron (found in animal products), but it can still contribute to increasing iron levels in the body, especially when combined with other sources of iron.
Choice B rationale:
Eat red meat just until the anemia is resolved is not a suitable instruction for a vegetarian client. Red meat is a source of heme iron, which is not part of a vegetarian diet. While heme iron is more easily absorbed by the body, there are other plant-based sources of iron that can be recommended to the client without compromising their dietary preferences.
Choice C rationale:
Lentils and black beans are excellent choices for a vegetarian client to increase iron intake. Both foods are rich in iron, and they also contain other nutrients that aid in iron absorption, such as vitamin C. Including lentils and black beans in soups can be a tasty and nutritious way to enhance iron intake.
Choice D rationale:
Increasing green leafy vegetables in the diet is another appropriate recommendation for a vegetarian client. Green leafy vegetables, such as spinach and kale, contain non-heme iron, as well as other essential vitamins and minerals that contribute to overall health. Combining them with vitamin C-rich foods can enhance iron absorption.
Choice E rationale:
Take two prenatal vitamins with iron daily is not necessary since the healthcare provider already prescribed one prenatal vitamin with iron daily. Taking additional supplements without medical advice can lead to an excessive intake of certain nutrients, which may have adverse effects on health.
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