A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
Advise the UAP to resume positioning the client on schedule.
Encourage the UAP to provide comfort care measures only.
Assume total care of the client to monitor neurologic function.
Assign a practical nurse to assist the UAP in turning the client.
The Correct Answer is A
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.
Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.
Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.
Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.
Correct Answer is A
Explanation
Choice A reason: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.
Choice B reason: Lower extremity edema is not typically an immediate concern post-alteplase administration unless it indicates a deep vein thrombosis.
Choice C reason: Paroxysmal supraventricular tachycardia requires monitoring, but it is not as urgent as a headache with blurred vision, which could signify a life-threatening complication.
Choice D reason: Frequent premature ventricular contractions should be monitored, but they are not as critical as a headache with blurred vision post-alteplase.
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