An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
Administer a prescribed PRN benzodiazepine at the onset of a confused state.
Ensure that the client is assigned to a room close to the nurses' station.
Postpone administration of nighttime medications until after 2300.
Ask family members to remain with the client in the evenings from 1700 to 2000.
The Correct Answer is B
A. Administering a PRN benzodiazepine is a reactive measure and might not be the best first line of intervention for managing the client's restlessness and confusion, as it does not address the underlying issue.
B. Assigning the client to a room close to the nurses' station can help manage restlessness, confusion, and agitation by ensuring the client is monitored more closely and can receive timely interventions.
C. Postponing nighttime medications might not address the immediate issues of restlessness and confusion, and could potentially disrupt the client's sleep-wake cycle.
D. Asking family members to stay with the client provides support but may not be a feasible or consistent solution for managing the client’s evening agitation and restlessness.
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Related Questions
Correct Answer is D
Explanation
A. While postmenopausal use of herbal estrogen may be a risk factor for breast cancer, it is not as significant as having a family history of the disease.
B. A history of fibrocystic changes and a painful lump are not as strong a risk factor for breast cancer as a family history of the disease.
C. Being of normal weight, height, and having children at a younger age are generally considered protective factors rather than risk factors for breast cancer.
D. A non-tender lump combined with a family history of breast cancer (mother with breast cancer) is the most significant risk factor for developing breast cancer.
Correct Answer is B
Explanation
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
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