A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following action should the nurse take?

Administer a sedative to the client

Contact a family member to come and sit with the client

Place the client in a wheelchair with a lap tray

Keep the client in her room with the door closed

Answer and Explanation

The Correct Answer is B

a. Administer a sedative to the client:

Administering a sedative may temporarily calm the client, but it should not be the first-line intervention, especially without a physician's order. Sedatives carry risks and should only be used when other interventions have been considered and deemed ineffective or when the client's behavior poses an immediate danger to themselves or others.

b. Contact a family member to come and sit with the client: could indeed be a valid first step. If a family member is available and able to assist, they could potentially calm the client without the need for isolation and reducing disruptive behavior. However, if this is not feasible, then ensuring the client’s safety through temporary isolation with frequent checks might be necessary.

c. Place the client in a wheelchair with a lap tray:

Placing the client in a wheelchair with a lap tray may restrict their movement and potentially exacerbate agitation or aggression. It does not address the underlying reasons for the behavior and may not be an appropriate intervention for managing wandering behavior.

d. Keep the client in her room with the door closed:

Isolating a client in their room could be considered a form of restraint or isolation and should be used with caution. This should be used only after other less restrictive measures have been tried and deemed ineffective.

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Correct Answer is A

Explanation

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

A. Establishing communication between provider’s B. Developing client treatment protocols C. Assessing client needs D. Providing medication reconciliation

Correct Answer is C

Explanation

a. Establishing communication between providers:

Telehealth can facilitate communication between healthcare providers, allowing them to consult, collaborate, and share information about patient care remotely. This includes discussing patient cases, sharing test results, and coordinating treatment plans.

b. Developing client treatment protocols:

While telehealth may involve the use of protocols and guidelines to guide care delivery, its primary objective is to provide healthcare services remotely rather than developing treatment protocols specifically.Treatment protocols are typically established during a comprehensive assessment, which telehealth can be a part of, but it's not the sole purpose of a client call

c. Assessing client needs:

This is a core objective of telehealth. It allows healthcare professionals to evaluate the client's current health status, gather relevant information, and determine the necessary next steps in their care remotely.

d. Providing medication reconciliation:

Telehealth can facilitate medication reconciliation by allowing healthcare providers to review a patient's medication list remotely, update medication records, and reconcile any discrepancies during virtual appointments.

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A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following should the nurse assess first?

Correct Answer is A

Explanation

A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?

Correct Answer is C

Explanation

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