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","C","E"]
Explanation
A. Use standard precautions and wear a mask.
While standard precautions should always be followed to prevent the spread of infection, wearing a mask is not specifically indicated for MRSA unless there is a risk of respiratory transmission. Contact precautions are more appropriate for MRSA.
B. Institute contact precautions for staff and visitors.
Contact precautions are necessary to prevent the spread of MRSA, a highly contagious bacteria. This involves using gloves and gowns when entering the client's room to prevent transmission of the bacteria to others.
C. Send wound drainage for culture and sensitivity.
Culturing the wound drainage helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment (sensitivity testing).
D. Explain the purpose of a low bacteria diet.
A low bacteria diet is not typically indicated for managing MRSA infections. Instead, the focus should be on wound care, antibiotic therapy, and infection control measures to address the MRSA infection.
E. Monitor the client's white blood cell count.
Monitoring the white blood cell count helps assess the client's immune response and the severity of the infection. Elevated white blood cell counts may indicate an active infection and the need for further intervention.
Correct Answer is ["0.5"]
Explanation
To find out how many milliliters the nurse should administer, we first need to calculate the volume required to deliver 200 mg of streptomycin.
Given:
Streptomycin concentration: 1 gram/2.5 mL
Dose prescribed: 200 mg
We'll start by converting the dose prescribed from milligrams (mg) to grams (g) since the concentration is given in grams:
200 mg = 0.2 grams
Now, we can set up a proportion to find the volume (x) needed to deliver 0.2 grams of streptomycin:
1 gram / 2.5 mL = 0.2 grams / x
Cross-multiplying:
1 * x = 0.2 * 2.5
x = 0.5 mL
So, the nurse should administer 0.5 milliliters of streptomycin.
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