Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

Move the client to a room closer to the nurse's station.

Apply wrist and leg restraints to the client.

Administer medication to sedate the client.

Call the family and ask them to stay with the client.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Moving the client to a room closer to the nurse's station is a non-invasive measure that allows for closer observation and quicker intervention if the client's condition worsens. It provides safety without compromising the client's autonomy or dignity.

Choice B reason:

Applying wrist and leg restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and confusion, and they carry a risk of injury. They should only be used when less restrictive measures have failed and the client is at immediate risk of harm to themselves or others.

Choice C reason:

Administering medication to sedate the client may be appropriate in certain situations, but it should not be the first action taken. Sedation can mask underlying conditions and may lead to further complications. It is important to assess the cause of the client's restlessness and confusion before considering sedation.

Choice D reason:

Calling the family to ask them to stay with the client can provide comfort and may help to orient the client. However, this may not always be feasible, and it does not address the immediate safety needs of the client in the same way that moving them closer to the nurse's station does.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

The correct answer is: B and D.

Choice A: Heart Failure

Heart failure is a potential complication of anorexia nervosa due to malnutrition and electrolyte imbalances, which can affect cardiac function. However, the client’s current diagnostic results do not directly indicate heart failure. The blood pressure and heart rate are low but not critically so, and there are no specific cardiac markers or symptoms mentioned that would suggest imminent heart failure.

Choice B: Renal Failure

Renal failure is a significant risk for this client. The elevated BUN (31 mg/dL) and creatinine (3.0 mg/dL) levels indicate impaired kidney function. These values are well above the normal ranges (BUN: 10-20 mg/dL, creatinine: 0.5-1.0 mg/dL), suggesting that the kidneys are not effectively filtering waste products from the blood. This is consistent with renal failure, which can be exacerbated by dehydration and electrolyte imbalances common in anorexia nervosa.

Choice C: Hypomagnesemia

Hypomagnesemia refers to low magnesium levels in the blood. The client’s magnesium level is 2.2 mEq/L, which is within the normal range (1.3-2.1 mEq/L). Therefore, hypomagnesemia is not a current risk for this client based on the provided lab results.

Choice D: Hypothyroidism

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. The client’s free thyroxine (T4) level is 0.4 ng/dL, which is below the normal range (0.8-2.8 ng/dL). This indicates hypothyroidism, which can cause symptoms such as fatigue, weight gain, and depression78. Given the client’s history of anorexia nervosa and the current lab results, hypothyroidism is a significant risk.

A. Explaining unit rules and policies regarding unacceptable behaviors B. Making sure the client understands expectations for client participation C. Encouraging client feedback about satisfaction with the facility experience D. Supporting the client's wish to refuse prescribed medications

Correct Answer is D

Explanation

Choice A reason:

Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining a safe and therapeutic environment, but it does not directly demonstrate the ethical concept of autonomy. Autonomy involves respecting the client's right to make their own decisions.

Choice B reason:

Ensuring that the client understands expectations for client participation is part of providing education and setting boundaries within the therapeutic relationship. While this is important, it is not a direct demonstration of autonomy, which is about the client's right to make choices.

Choice C reason:

Encouraging client feedback about satisfaction with the facility experience is a way to involve clients in the evaluation of services, which can be related to autonomy. However, it is more about gathering information to improve the facility rather than supporting the client's individual rights and choices.

Choice D reason:

Supporting the client's wish to refuse prescribed medications is a direct demonstration of the ethical concept of autonomy. It respects the client's right to self-determination and their ability to make decisions about their own health care, even if those decisions are different from what the healthcare team recommends.

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Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Choice A: Heart Failure

Choice B: Renal Failure

Choice C: Hypomagnesemia

Choice D: Hypothyroidism

A nurse is caring for a client diagnosed with a mental illness on a psychiatric unit. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is D

Explanation

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According to Bowen's theoretical approach to therapy, which of the following should the nurse recognize as a concept of a functional family interaction pattern?

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A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)

A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?