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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
Correct Answer is C
Explanation
Choice A reason: Asking the client's daughter to interpret the conversation is not a correct action, as it may compromise the accuracy and confidentiality of the information. The nurse should not use family members or friends as interpreters, as they may have biases, emotions, or personal agendas that could interfere with the communication.
Choice B reason: Talking loudly while facing the client is not a correct action, as it may be perceived as rude or aggressive by the client. The nurse should not assume that the client can understand them better by increasing the volume or using gestures, as these may have different meanings in different cultures.
Choice C reason: Accessing a language line to interpret what is being said is the correct action, as it ensures that the communication is clear, accurate, and respectful. The nurse should use a qualified interpreter who is familiar with the medical terminology and the cultural context of the client.
Choice D reason: Using a bilingual dictionary to translate is not a correct action, as it may be time-consuming and ineffective. The nurse should not rely on a dictionary or a translation app, as they may not capture the nuances or expressions of the language. The nurse should also avoid using medical jargon or slang that may not be understood by the client.
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