A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
Check the client for injuries.
Obtain a prescription for medication to sedate the client.
Call the family and ask them to make arrangements for someone to sit with the client.
Assist the client back into bed and apply restraints.
The Correct Answer is A
The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.
Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.
Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.
Correct Answer is A
Explanation
The nurse should call emergency medical services if they find a woman who has collapsed with right-sided weakness and slurred speech. These symptoms could indicate a stroke or other serious medical condition that requires immediate medical attention.
Finding a location for the client to sit, driving the client to the nearest emergency room, and obtaining the number of the client's provider are not appropriate initial actions for the nurse to take in this situation. The priority is to get the client immediate medical attention by calling emergency medical services.
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