A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.
Orient the client to their surroundings.
Close the client's room door.
Escort the client back to the room.
Raise the four side rails on the bed.
Secure a bed alarm on the mattress.
Correct Answer : A,C,E
Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.
Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.
Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.
Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.
Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Excessive pressure can occlude arterial flow, preventing detection of the dorsalis pedis pulse. Reducing pressure allows blood flow to be felt, improving accuracy of pulse assessment.
Choice B rationale: Documentation without rechecking risks inaccurate reporting. Pulses may be present but obscured by technique, so confirming with proper palpation or alternative methods is necessary before recording findings.
Choice C rationale: Doppler stethoscope is useful but should be considered after correcting palpation technique. Initial step is adjusting pressure, as improper technique commonly explains absent pulse detection.
Choice D rationale: Palpating posterior tibial pulse assesses a different artery. While useful for circulation evaluation, it does not address the immediate issue of dorsalis pedis pulse palpation technique.
Correct Answer is C
Explanation
Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.
Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.
Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.
Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.
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