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 C
Explanation
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
Correct Answer is C
Explanation
A. Trying not to listen to the conversation does not address the issue of confidentiality breach or protect the client's privacy.
B. Writing an incident report might be necessary, but the immediate action should be to stop the conversation to protect the client's confidentiality.
C. Approaching the individuals involved and asking them to stop is the most appropriate and immediate action to protect the client's privacy and confidentiality.
D. Telling the client about the UAP's concern might not be suitable without context or proper consent, and it might not address the confidentiality breach.
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