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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.
Correct Answer is C
Explanation
A. Notifying the charge nurse is important but should come after confirming the accurate heart rate assessment.
B. Holding a prescribed morning dose of digoxin may be necessary if bradycardia is confirmed, but the first step is to accurately assess the heart rate.
C. Obtaining a full minute apical pulse assessment is the first step to verify the radial pulse rate reported by the UAP and ensure an accurate and comprehensive assessment of the client's heart rate.
D. Reviewing the client's baseline vital signs is useful but should follow a thorough and accurate assessment of the current heart rate.
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