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?
Oriented x 3.
Oriented x 1.
Oriented x 2.
Oriented x 4.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Taking prophylactic prescriptions for diarrhea can prevent or minimize gastrointestinal issues post-disaster.
Drinking boiled water or bottled oral rehydration solutions reduces the risk of waterborne diseases.
Washing fruits and vegetables in running tap water removes contaminants.
Cleaning hands with soap, clean water, or antibacterial solutions prevents the spread of infections.
Identifying sexual contacts isn't directly related to immediate post-disaster health concerns.
Correct Answer is C
Explanation
A. Obliterating the entry could make the record look messy and might not meet documentation standards.
B. Notifying the charge nurse might be appropriate for major errors or if the policy requires it, but it might not be necessary for a simple correction like this.
C. Drawing a single line through the erroneous entry and inserting the correct information maintains the integrity of the chart and shows the correction clearly.
D. Charting the correct information in the next column might create confusion about the sequence of data and might not clearly indicate the correction made.
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