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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.

A. Apply an ice pack for 20 minutes to the episiotomy. B. Observe suture line for separation and hematoma formation. C. Initiate daily warm sitz baths during onset of pain. D. Check medication administration record for last PRN analgesic.

Correct Answer is B

Explanation

A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

Correct Answer is A

Explanation

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

Correct Answer is B

Explanation

The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. Which action should the PN take?

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an older adult client has a radial pulse of 55 beats/minute. Which intervention should the PN implement first?

According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

Exhibits The practical nurse (PN) would like to encourage the client to take oral fluids so that the IV fluids can eventually be discontinued. Which three strategies would be most effective in getting a client to consume adequate oral fluids?

Exhibits The practical nurse (PN) suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.