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. A sterile glove the PN thinks might have touched her hair: Once sterility is in doubt, the item must be considered contaminated. Hair carries microorganisms, and any possible contact violates aseptic technique.
B. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top: Moisture carries microorganisms by capillary action, contaminating sterile objects on a wet surface. The pad is therefore no longer considered sterile.
C. An open sterile Foley catheter kit set up on a table at the PN's waist level: The sterile field is maintained above waist level, within the PN’s direct view, and on a dry surface. This setup adheres to the principles of asepsis and can be considered sterile.
D. A one-inch border around the edges of a sterile field set up in the operating room: The one-inch border is always considered contaminated, not sterile, because it may come into contact with nonsterile surfaces during setup or handling.
Correct Answer is D
Explanation
A. Reinforce PCA pump teaching: Teaching about PCA use is important, but it is not the immediate priority when a client shows signs of lethargy. Education can be addressed later, once the client’s condition has been stabilized and safety is ensured.
B. Check the IV insertion site for swelling: Inspecting the IV site for infiltration or phlebitis is a routine step, but it does not address the potential systemic effect of morphine causing central nervous system depression.
C. Determine the client's pain scale rating: Assessing pain level is typically part of routine evaluation for clients on PCA, but when lethargy develops, the focus must shift to assessing possible opioid toxicity rather than pain relief effectiveness.
D. Measure the client's vital signs: Obtaining vital signs is the most immediate and appropriate action. Respiratory depression, hypotension, or bradycardia may indicate opioid overdose or excessive sedation. Prompt assessment allows the PN to recognize early signs of morphine toxicity and intervene quickly to prevent respiratory compromise.
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