A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
Provide a back rub at bedtime.
Leave the door to the client's room open slightly.
Apply wrist restraints to prevent wandering.
Administer a PRN sedative prescription.
The Correct Answer is A
A. Provide a back rub at bedtime:
This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.
B. Leave the door to the client's room open slightly:
Leaving the door open may not prevent wandering and could potentially lead to safety issues.
C. Apply wrist restraints to prevent wandering:
Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.
D. Administer a PRN sedative prescription:
Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Capillary refill of 2 seconds in the lower right foot:
Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.
B. Basilar lung sounds that are diminished in the left lung:
Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.
C. Contraction of the left pupil when light shines in the right eye:
Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.
D. Active bowel sounds in the lower right quadrant:
Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.
Correct Answer is C
Explanation
A. Blood pressure is 142/88 mm Hg:
While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.
B. Radial pulse volume is 3+:
A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.
C. 2+ edema of fingers and hands:
Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.
D. Capillary refill time is 2 seconds:
Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.
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