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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Provide volunteers who will run errands for her is incorrect. While respite care services may offer some assistance with errands or tasks, the primary purpose of respite care is to provide temporary relief and support to caregivers by allowing them to take a break from their caregiving responsibilities.
Choice B Reason:
Sending a clinician to assess the safety of leaving her partner alone is incorrect. While ensuring the safety of the client is important, assessing the safety of leaving the partner alone does not directly relate to respite care. Respite care focuses on providing temporary relief to caregivers rather than assessing the client's ability to be left alone.
Choice C Reason:
Allowing her to take time off from attending to her partner is correct. Respite care provides caregivers with the opportunity to take a break from their caregiving responsibilities and attend to their own needs, whether it's for rest, relaxation, or attending to personal matters. It allows caregivers to recharge and prevent burnout.
Choice D Reason:
Helping her arrange transferring her partner to an assisted living facility is incorrect. Respite care is not typically intended to assist with arranging long-term care options such as transferring a partner to an assisted living facility. It focuses on providing short-term relief for caregivers, allowing them to continue providing care in their own homes.
Correct Answer is C
Explanation
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.
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