A nurse is caring for a client who is experiencing acute delirium and has slipped down in their bed. Which of the following actions should the nurse take when repositioning the client?
Raise the rail on the side of the client's bed closest to the nurse.
Ask an assistive personnel to help move the client up in bed.
Ask the client to straighten their knees while pulling them up in bed.
Place the client in low-Fowler's position prior to moving them.
The Correct Answer is B
A. Raise the rail on the side of the client's bed closest to the nurse:
Raising the rail closest to the nurse may hinder access and compromise safety during repositioning. It's better to lower the rail on the working side.
B. Ask an assistive personnel to help move the client up in bed:
Clients with delirium need two-person assistance to safely reposition and prevent injury.
C. Ask the client to straighten their knees while pulling them up in bed:
A client with acute delirium may be confused or unable to follow instructions, making this unsafe.
D. Place the client in low-Fowler's position prior to moving them:
Low-Fowler’s may be used after repositioning, but does not assist in the actual movement up in bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Number scale
Requires verbal communication and abstract reasoning, not appropriate for advanced dementia.
B. Color scale
Also requires cognitive recognition that may be impaired in dementia.
C. Behavioral pain scale
This scale assesses pain using facial expression, body movements, and vocalizations.
D. Pieces of pain scale
This is generally used for pediatric clients, not those with dementia.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Condition – Ectopic pregnancy; Finding – Right lower quadrant abdominal tenderness
Ectopic pregnancy – Right lower quadrant abdominal tenderness
A missed period, positive hCG, and right lower quadrant pain are classic signs of ectopic pregnancy, a life-threatening condition.
Other combinations are ruled out as follows:
- Placenta previa – Incorrect: Usually presents in later pregnancy with painless bright red bleeding.
- Pyelonephritis – Temperature – Incorrect: The client has normal temperature and no urinary symptoms.
- Acute asthma attack – Hyperactive bowel sounds – Incorrect: No respiratory distress or wheezing; hyperactive bowel sounds are GI-related.
- Abruptio placentae – Respiratory rate – Incorrect: RR is normal and this condition is also more likely in later pregnancy
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