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 A

Explanation

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

A. Marital skew. B. Sibling position. C. Pseudomutuality. D. Double-bind communication.

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.

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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

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

According to Bowen's theoretical approach to therapy, which of the following should the nurse recognize as a concept of a functional family interaction pattern?

Correct Answer is B

Explanation

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