An older male resident of a long-term care facility is awake at 3:30 AM and wandering down the hall with his pajamas unbuttoned. Which intervention should the practical nurse (PN) Implement?
Address the client to determine his needs.
Administer a nighttime sedative.
Bring the client to sit in the nursing station.
Direct the client to go back to bed.
The Correct Answer is A
A. Address the client to determine his needs: The most appropriate intervention is to calmly approach the resident, assess his orientation, and determine what he needs. Older adults may wander due to confusion, discomfort, or unmet needs such as hunger, toileting, or pain.
B. Administer a nighttime sedative: Sedatives should not be given without a clear medical indication or provider order, as they increase the risk of falls, confusion, and dependency in older adults. Medication is not the first-line approach for managing nighttime wandering.
C. Bring the client to sit in the nursing station: Bringing the resident to the nursing station may offer temporary supervision but does not address the underlying reason for wandering. It may also cause disorientation or agitation if the environment is bright or noisy.
D. Direct the client to go back to bed: Simply instructing the resident to return to bed may be ineffective and distressing if he is confused or restless. A calm, needs-based approach that prioritizes understanding the cause of the behavior is safer and more therapeutic.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Presence of an indwelling catheter: An indwelling catheter does not typically require additional personnel for safe transfer. Standard precautions and careful positioning are usually sufficient.
B. Stage two pressure ulcer on right buttock: While care must be taken to avoid pressure on the ulcer, a stage two ulcer does not usually necessitate extra assistance for a safe transfer. Proper technique and padding can protect the site.
C. Low grade fever and warm, dry skin: Mild fever and skin warmth do not affect the client’s ability to participate in a transfer and do not require additional personnel.
D. Impaired cognition and agitation: Clients who are confused or agitated may be unpredictable and pose a safety risk during transfers. Requesting assistance ensures both client and nurse safety, allowing for controlled and safe movement to the wheelchair.
Correct Answer is B
Explanation
A. "Come into the recreation area. We have your favorite card game and I will play it with you.": While offering an activity may seem helpful, it may feel overwhelming or pushy to a reclusive, depressed resident.
B. "May I sit with you for a while?": Sitting quietly together can help build trust, provide emotional support, and encourage gradual social interaction, which is most appropriate for someone who is withdrawn and experiencing chronic depression.
C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can.": Attempting to rationalize the client’s feelings may minimize his emotional experience. While factual, this statement may feel dismissive of his grief.
D. "Why do you want to stay in your room today?": Asking “why” questions can feel confrontational or judgmental to a depressed and withdrawn resident. It may prompt defensiveness rather than encourage meaningful communication or provide comfort.
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