A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?
Medicate the client with alprazolam.
Reorient the client to his surroundings.
Measure the client's vital signs.
Offer reassurance to the family.
The Correct Answer is C
Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A sufficient supply of personal protective equipment is appropriate. Bioterrorism events can involve the deliberate release of biological agents, such as bacteria, viruses, or toxins, with the intent to cause harm to individuals or populations. In such events, personal protective equipment (PPE) is critical for protecting healthcare workers and first responders from exposure to infectious agents and toxins. Adequate supplies of PPE, including masks, gloves, gowns, and eye protection, are essential to ensure the safety of healthcare workers and to prevent the spread of infection.
Choice B Reason:
A network for communication between staff members and families, is important for coordinating care and providing updates during a disaster, but it is not the highest priority when addressing immediate safety concerns related to a bioterrorism event.
Choice C Reason:
A mental health specialist on the response team, is important for providing support to individuals affected by the disaster, but it is not the highest priority during the initial response phase focused on safety and containment.
Choice D Reason:
A system for tracking client information, is important for maintaining continuity of care and tracking patient outcomes, but it is not the highest priority in the immediate response to a bioterrorism event when protecting healthcare workers and preventing further spread of infection is paramount.
Correct Answer is A
Explanation
Choice A Reason:
Shredding extra copies of a client's records is essential to maintaining confidentiality and protecting the client's privacy. This ensures that sensitive information is properly disposed of and cannot be accessed by unauthorized individuals.
Choice B Reason:
While confirming the fax number before sending the client's information is essential, doing so after sending the information is not useful and can potentially lead to privacy breaches if the information was sent to the wrong number. The correct action would be to verify the fax number before sending the information.
Choice C Reason:
Avoid using a fax cover sheet in order to reduce paper waste is inappropriate. While reducing paper waste is important for environmental sustainability, using a fax cover sheet is typically necessary for providing necessary information and ensuring that the fax is properly directed to the intended recipient. Omitting a fax cover sheet may lead to confusion or misdirection of the faxed information.
Choice D Reason:
Sending the facility, a copy of the client's complete medical record is inappropriate. While it may be necessary to send relevant portions of the client's medical record to the rehabilitative facility, sending the entire medical record may be excessive and could potentially violate the client's privacy rights. It's important to send only the information that is pertinent to the client's transfer and rehabilitation needs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.