A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Administer medication to sedate the client.

Call the family and ask them to stay with the client.

Apply wrist and leg restraints to the client.

Move the client to a room closer to the nurses' station.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.

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Correct Answer is B

Explanation

The correct answer is choice: B. Sibling position.

Choice A rationale:

Marital skew is not a concept associated with Bowen's family systems theory. It does not correspond to any recognized pattern in this theoretical approach.

Choice B rationale:

Sibling position is an important concept in Bowen's family systems theory. It refers to the birth order of siblings within a family and how this birth order can influence the roles and dynamics within the family unit.

Choice C rationale:

Pseudomutuality is not a concept of Bowen's family systems theory. This term does not align with the terminology or principles of this theoretical approach.

Choice D rationale:

Double-bind communication is a concept introduced by Gregory Bateson and is associated with the communication patterns within dysfunctional families. While it is related to family interactions, it is not specifically attributed to Bowen's theoretical approach.

A. Demonstrate genuineness when communicating. B. Focus on the words of the clients. C. Control the pace of establishing the nurse-client relationships. D. Provide sympathy during interactions.

Correct Answer is A

Explanation

Choice A rationale:

Demonstrating genuineness involves being authentic, sincere, and transparent in interactions with clients. This helps build trust by showing that the nurse's intentions and emotions align with their words. Genuineness fosters a sense of safety and openness in the therapeutic relationship.

Choice B rationale:

While focusing on the words of the clients is important, it's not the only factor. Nonverbal cues, emotions, and context also play significant roles in effective communication. Only focusing on words could result in missing important nuances and emotions.

Choice C rationale:

Controlling the pace of the nurse-client relationship contradicts the principle of client-centered care, where the client's readiness and comfort should guide the pace. Pushing the pace might lead to resistance or discomfort, hindering the development of trust.

Choice D rationale:

Providing sympathy involves expressing pity or sorrow for the client's situation. However, empathy, which involves understanding and sharing the client's feelings, is more appropriate. Sympathy might create a sense of pity, while empathy establishes a deeper connection and understanding.

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A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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