A nurse is reviewing the plan of care for an older adult client who is oriented during the day but has recently become confused at night. Which of the following interventions should the nurse recommend to update the client's plan of care?

Transfer the client to a private room away from the nurses' station.

Request a PRN prescription for an antianxiety medication.

Advise family members not to visit the client after the evening meal.

Recommend a stimulating activity when the client becomes confused.

Answer and Explanation

The Correct Answer is D

A. Transfer the client to a private room away from the nurses' station: Moving the client away from the nurses’ station may increase feelings of isolation and anxiety, potentially worsening confusion at night. Environmental changes should support orientation and safety, not exacerbate disorientation.

B. Request a PRN prescription for an antianxiety medication: Sedative medications may temporarily reduce agitation but can increase the risk of falls, oversedation, and delirium in older adults. Non-pharmacologic interventions are preferred for managing confusion and sundowning.

C. Advise family members not to visit the client after the evening meal: Restricting family visits may increase feelings of loneliness and anxiety. Supportive family presence often helps orient and calm the client rather than aggravate confusion.

D. Recommend a stimulating activity when the client becomes confused: Engaging the client in structured, stimulating activities in the evening can help maintain orientation, reduce boredom, and decrease episodes of confusion. Non-pharmacologic interventions like this are effective in managing sundowning in older adults.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Verify the employer's identity prior to disclosing information: While verifying the caller’s identity is important for security, it does not address the requirement for consent before sharing private health information. Identity verification alone does not authorize disclosure.

B. Refer the employer to the charge nurse to share the client's information: Referring the employer does not resolve the legal and ethical obligation to protect client confidentiality. Sharing information without client consent is prohibited, regardless of who the nurse contacts.

C. Contact the client's family to verify the client's employment status: Involving the client’s family without consent violates privacy and confidentiality. Employment status alone does not justify disclosure of health information to family or employer.

D. Obtain the client's permission to share their health care information: Health information is protected under HIPAA and ethical standards. The nurse must secure explicit consent from the client before discussing their condition with the employer to maintain confidentiality and legal compliance.

A. A client in the dayroom who is screaming at other clients about what is on the television B. A client who has bipolar disorder and is continuously pacing at the end of the hall C. A client who is repeatedly approaching the nurses' station to request medication for their anxiety D. A client who is standing in their room, yelling obscenities, and throwing their clothes

Correct Answer is D

Explanation

A. A client in the dayroom who is screaming at other clients about what is on the television: This behavior is disruptive but does not pose an immediate safety threat to the client or others. The nurse should monitor and intervene as needed, but it is not the highest priority.

B. A client who has bipolar disorder and is continuously pacing at the end of the hall: Pacing may indicate agitation or restlessness, but if the client is not aggressive or threatening, it poses less immediate risk. The nurse should assess for escalation but prioritize clients with potentially dangerous behaviors first.

C. A client who is repeatedly approaching the nurses' station to request medication for their anxiety: While attention to anxiety is important, this behavior does not indicate imminent danger or risk of harm. It can be addressed after attending to clients who may be violent or unsafe.

D. A client who is standing in their room, yelling obscenities, and throwing their clothes: This client is exhibiting aggressive and potentially violent behavior that could escalate to self-harm or harm to others. Ensuring safety and de-escalation for this client takes priority over disruptive or non-threatening behaviors.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing the plan of care for an older adult client who is oriented during the day but has recently become confused at night. Which of the following interventions should the nurse recommend to update the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client's employer contacts the nurse to discuss the client's condition. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has bipolar disorder. Which of the following findings is the nurse's priority?

A nurse is reinforcing teaching with a client about haloperidol. Which of the following instructions should the nurse include in the teaching?

A nurse is reviewing a food diary with a client who has depression. Which of the following client food choices should the nurse identify as interacting with the client's prescribed medication?

A nurse is assisting in the admission of a client to an inpatient mental health facility. The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the charge nurse immediately? Select all that apply.

The nurse is assisting in the care of a client in an inpatient mental health facility. For which of the following manifestations of withdrawal is the client at risk? Select the 4 manifestations of withdrawal for which the client is at risk.

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)