A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Inform the client's family member.

Notify the client's provider.

Assist the client back into bed.

Answer and Explanation

The Correct Answer is A

A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signs provides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.

B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.

C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.

D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.

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Correct Answer is A

Explanation

A. Disorientation in an older adult after taking lorazepam could indicate an adverse reaction or an excessive sedative effect. It's crucial to report this immediately as it may signify an overdose or an adverse reaction to the medication. Older adults are more sensitive to the sedative effects of benzodiazepines, and disorientation can indicate potential serious side effects.

B. Anorexia (loss of appetite) is a possible side effect of lorazepam but is not typically considered an urgent or immediate concern unless it leads to severe dehydration or other complications.

C. Increased anxiety could potentially occur due to paradoxical reactions to benzodiazepines; however, it's not typically considered an urgent or immediate concern unless it's severe or distressing to the client.

D. Blurred vision is a common side effect of lorazepam and other benzodiazepines. While it should be monitored and reported, it might not be considered an urgent concern unless it's significantly affecting the client's ability to function or is accompanied by other severe symptoms.

A. Keep the client's personal items within reach. B. Tell the family that someone should plan to stay with the client. C. Place the client in a quiet room at the end of the hallway. D. Provide bright lighting in the client's room at night.

Correct Answer is A

Explanation

A. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.

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A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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