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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Offering positive reinforcement is a good practice in teaching, but it does not directly facilitate the learning of problem-solving strategies.

Choice B reason: Physical demonstrations are more suited to teaching psychomotor skills rather than problem-solving strategies.

Choice C reason: Simulation activities allow individuals to practice problem-solving in a controlled environment, which can enhance learning and retention of these strategies.

Choice D reason: Verbal analogies can aid in understanding concepts, but they are less interactive and engaging than simulation activities when it comes to learning problem-solving strategies.

A. Provide at least 20 minutes of back massage and gentle efleurage. B. Instruct the client to use guided imagery and slow rhythmic breathing. C. Place a hot water circulation device, such as an aquathermia pad, on the operative site. D. Tune to a television show or easy listening music to provide distraction.

Correct Answer is A

Explanation

Choice A reason: Providing a back massage and gentle efleurage can help alleviate pain through relaxation
techniques and is a non-pharmacological method to manage pain.

Choice B reason: Guided imagery and slow rhythmic breathing are helpful relaxation techniques, but they may not be as immediately effective for incisional pain as direct physical interventions.

Choice C reason: The use of a hot water circulation device should be done with caution postoperatively, as it may not be appropriate depending on the surgical site and the client's condition.

Choice D reason: Distraction techniques like watching television or listening to music can be helpful, but they may not address the physical component of the client's incisional pain.

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A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

Correct Answer is C

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is A

Explanation

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

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