A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?

Obtain a prescription for a sedative for the client.

Remove the clock and calendar from the client's room.

Provide distractions for the client during the day.

Raise all four side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining a prescription for a sedative for the client is not a correct action, as it may cause adverse effects such as confusion, falls, or respiratory depression. The nurse should avoid using sedatives unless absolutely necessary and use non-pharmacological interventions to calm the client.

Choice B reason: Removing the clock and calendar from the client's room is not a correct action, as it may worsen the client's disorientation and anxiety. The nurse should provide orientation cues such as a clock, a calendar, a radio, or a newspaper to help the client maintain a sense of time and reality.

Choice C reason: Providing distractions for the client during the day is a correct action, as it may reduce the client's boredom, agitation, and wandering behavior. The nurse should engage the client in meaningful activities such as music, games, crafts, or exercise that suit the client's interests and abilities.

Choice D reason: Raising all four side rails on the client's bed is not a correct action, as it may increase the risk of injury or entrapment if the client tries to climb over them. The nurse should use the least restrictive measures to prevent wandering, such as alarms, locks, or supervision.

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Correct Answer is A

Explanation

Choice A reason: This is the first action the nurse preceptor should take to demonstrate appropriate time management. By determining the client care goals, the nurse preceptor can prioritize the most important and urgent tasks for each client and delegate appropriately.

Choice B reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Reviewing the client's new laboratory values is an important task, but it should be done after determining the client care goals and before completing the required tasks.

Choice C reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Completing the required tasks is an essential part of nursing care, but it should be done after determining the client care goals and reviewing the client's new laboratory values.

Choice D reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Documenting the assessment data is a vital part of nursing care, but it should be done after completing the required tasks and before the end of the shift.

A. Recommend the son meet with the provider to get information about his mother's condition. B. Complete an incident report regarding the breach of the client's confidentiality. C. Log out the computer so that the client's son is unable to view his mother's information. D. Report the possible violation of client confidentiality to the nurse manager.

Correct Answer is C

Explanation

Choice A reason: This is not the correct choice because recommending the son meet with the provider to get information about his mother's condition is not the first action the nurse should take. The nurse should first stop the unauthorized access to the client's records and protect the client's privacy and confidentiality. The nurse can then offer to arrange a meeting with the provider if the son has questions or concerns.

Choice B reason: This is not the correct choice because completing an incident report regarding the breach of the client's confidentiality is not the first action the nurse should take. The nurse should first intervene to prevent further disclosure of the client's information and secure the computer. The nurse can then document the incident and follow the facility's policy and procedure for reporting such events.

Choice C reason: This is the correct choice because logging out the computer so that the client's son is unable to view his mother's information is the first action the nurse should take. The nurse should act quickly and assertively to terminate the unauthorized access to the client's records and safeguard the client's rights. The nurse should also explain to the son why his action was inappropriate and how it violated the client's confidentiality.

Choice D reason: This is not the correct choice because reporting the possible violation of client confidentiality to the nurse manager is not the first action the nurse should take. The nurse should first address the immediate situation and ensure that the client's information is no longer accessible to the son. The nurse can then inform the nurse manager and the provider about the incident and the actions taken.

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A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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