To determine a hospitalized client's orientation, the practical nurse should ask the client questions related to which information? (Select all that apply.)
When spouse died.
Season of the year.
Past surgeries.
Client's name.
Reason for hospitalization.
Present location.
Correct Answer : B,D,E,F
A. When spouse died: This is related to remote memory, not orientation to person, place, or time. While it may help assess long-term memory, it does not indicate the client’s current orientation.
B. Season of the year: This assesses orientation to time, helping determine whether the client is aware of the current temporal context, which is essential for evaluating cognitive status.
C. Past surgeries: This evaluates past medical history and long-term memory rather than current orientation. It does not reflect awareness of person, place, or time.
D. Client's name: Asking the client’s name assesses orientation to self (person), a core component of determining cognitive awareness and mental status.
E. Reason for hospitalization: This question evaluates orientation to situation or circumstance, indicating whether the client understands why they are in the hospital and the purpose of current care.
F. Present location: Asking where the client is assesses orientation to place, confirming awareness of the immediate environment and safety awareness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The percent of processed or canned foods eaten: Processed and canned foods are typically high in sodium, which would more likely lead to hypernatremia, not hyponatremia. Therefore, this information does not help determine the cause of a low sodium level.
B. The number of vegetable servings consumed daily: Vegetable intake has minimal impact on serum sodium levels unless accompanied by excessive fluid intake or specific medical conditions. This question does not directly address possible dilutional or sodium-loss causes.
C. The amount of ice chips and water consumed daily: Excessive intake of water or ice chips can lead to dilutional hyponatremia by lowering serum sodium concentration. Assessing fluid consumption is essential to determine if overhydration is contributing to the client’s low sodium level.
D. The amount of salt substitute used in meal preparation: Many salt substitutes contain potassium instead of sodium, which may alter potassium levels but not directly explain hyponatremia. The primary focus should be on identifying fluid-related factors rather than sodium replacement products.
Correct Answer is B
Explanation
A. Administer a PRN antianxiety agent: Medication may be necessary if nonpharmacologic interventions fail, but sedatives should not be the first-line approach for agitation related to dementia. Overmedication can increase confusion, fall risk, and other adverse effects.
B. Leave a night light on in her room: Providing adequate lighting helps reduce shadows and visual misperceptions that often trigger agitation in clients with dementia. This nonpharmacologic intervention promotes safety and orientation while addressing the root cause of the client’s fear.
C. Transfer the client to another room: Moving the client may increase disorientation and anxiety. Familiar surroundings help maintain a sense of security, making relocation a less desirable first intervention.
D. Tell her no one is behind the curtain: Directly challenging the client’s perception may escalate agitation. Clients with dementia often respond better to validation and environmental modifications rather than confrontation.
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