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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband" is non-therapeutic because it shifts the focus from the client to the nurse. This response demonstrates sympathy rather than empathy. Sympathy involves sharing one's own experiences and feelings, which can make the client feel unheard and invalidated. The nurse's role is to provide support and understanding without making the conversation about themselves.

Choice B Reason:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you" is more therapeutic. It acknowledges the client's feelings and offers support without shifting the focus to the nurse. This response shows empathy by validating the client's emotions and providing a comforting presence.

Choice C Reason:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is therapeutic as it recognizes the client's feelings and invites them to express their thoughts and emotions. This approach encourages open communication and helps the client feel understood and supported.

Choice D Reason:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" is also therapeutic. It acknowledges the client's emotional state and offers a practical solution to help manage their anxiety. This response shows empathy and provides an option for addressing the client's immediate needs.

A. "You will need your blood levels drawn weekly during the first month." B. "You will need to stop this medication if you develop severe diarrhea." C. "You will need to take this medication on an empty stomach." D. "You will need to consume a low-salt diet while on this medication."

Correct Answer is A

Explanation

Choice A Reason:

Monitoring blood levels of lithium is essential, especially during the initial phase of treatment. Lithium has a narrow therapeutic range, and its levels can fluctuate based on several factors, including diet, hydration, and renal function. Regular blood tests help ensure that the lithium concentration stays within the therapeutic range, preventing toxicity or subtherapeutic dosin.

Choice B Reason:

While it is important to monitor for side effects such as severe diarrhea, stopping the medication abruptly without consulting a healthcare provider is not recommended. Severe diarrhea can affect lithium absorption and lead to dehydration, which may necessitate a dosage adjustment rather than complete cessation.

Choice C Reason:

Lithium is typically taken with meals to reduce gastrointestinal side effects, not on an empty stomach. Taking lithium on an empty stomach can increase the risk of nausea, diarrhea, and other gastrointestinal issues.

Choice D Reason:

Patients on lithium are advised to maintain a consistent intake of sodium. A low-salt diet can lead to increased lithium retention, which can increase the risk of toxicity. Therefore, patients should not consume a low-salt diet unless advised by their healthcare provider for other medical reasons.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

Correct Answer is A

Explanation

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients with bipolar disorder? (Select all that apply.)

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?

Which of the following should be the appropriate action by a nurse attempting to develop a therapeutic relationship with a client?

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 an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?