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. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.

B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.

C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.

D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.

A. Institute rounds every 2 hr during the day to offer toileting B. Apply vest restraints on residents who are confused C. Accompany residents older than 85 years of age during ambulation D. Keep the four side rails up on beds at night

Correct Answer is A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

c. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

d. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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