At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes that someone is standing behind the privacy curtain. Which action should the practical nurse (PN) take?

Administer a PRN antianxiety agent.

Tell her no one is behind the curtain.

Transfer the client to another room.

Leave a night light on in her room.

Answer and Explanation

The Correct Answer is D

A.   Administer a PRN antianxiety agent. - This should be a last resort due to potential side effects.
Non-pharmacological interventions are usually preferable.
B.   Tell her no one is behind the curtain. - Arguing or contradicting her belief may escalate her agitation or confusion.
C.   Transfer the client to another room. - Moving her to a new environment might exacerbate her confusion and distress.
D.   Leave a night light on in her room. - This is a simple, non-intrusive intervention that can help reduce visual misinterpretations and provide comfort, potentially calming her agitation without confrontation or disruption.

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Correct Answer is A

Explanation

A. "May I sit with you for a while?" - This response offers companionship and emotional support without pushing the resident to engage in an activity or prying into his feelings. It respects his desire for solitude while providing the option for company if he wishes.
B. "Why do you want to stay in your room today?" - This might be perceived as intrusive and pushy, potentially making the resident more withdrawn.
C. "Come into the recreation area. We have your favorite card game and I will play it with you." - While well-intentioned, this suggestion may not align with the resident's current emotional state or desire for solitude.
D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." - This response acknowledges the resident's feelings but may not address his immediate need for companionship or support.

A. Oriented x 3. B. Oriented x 1. C. Oriented x 2. D. Oriented x 4.

Correct Answer is C

Explanation

A. Oriented x 3. - The client must recall the time, day, date, location, and reason for being there to be considered oriented x 3. As the client can only remember his name and location, it does not fulfill the criteria for oriented x 3.
B. Oriented x 1. - This is inaccurate as the patient is oriented in two aspects: person and place.
C. Oriented x 2. - The client recalls their name and place, hence is oriented in two aspects. This is therefore accurate.
D. Oriented x 4. - This would require the client to recall all four aspects of orientation (time, day, date, location, and reason for being there), which the client did not demonstrate in this scenario.

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At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes that someone is standing behind the privacy curtain. Which action should the practical nurse (PN) take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is A

Explanation

The practical nurse (PN) reorients a male client to the correct time, day, date, location, and why he is here today but he is only able to remember his name and where he is. Based on these findings, what should the PN document?

Correct Answer is C

Explanation

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