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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Administering the medication to a client behind a closed curtain:

Administering medication behind a closed curtain is not necessarily a tort. However, it may be a breach of privacy depending on the circumstances and the client's preferences.

B. Enlisting security personnel to assist with restraining the client:

Enlisting security personnel to assist with restraining an agitated client is not inherently a tort. It may be necessary to ensure the safety of the client and healthcare providers, depending on the situation.

C. Informing a client that the medication being administered is a vitamin:

Misinforming a client about the medication being administered is not a tort, but it is unethical and can lead to potential harm if the client does not receive appropriate treatment.

D. Placing a client in restraints without having a healthcare provider's order:

This action constitutes a tort known as false imprisonment. Restraints should only be applied when ordered by a healthcare provider and when necessary to ensure the safety of the client or others. Placing a client in restraints without proper authorization can lead to physical and psychological harm and is a violation of the client's rights.

A. Enter the occurrence after the 1400 notes and identify as "late entry". B. Request removal initiated by the Health Information Manager. C. Create an electronic correction after 1400 notes are officially unlocked. D. Make an electronic addendum following the 1400 documentation.

Correct Answer is A

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

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Explanation

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Correct Answer is A

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