An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?
Document the client's loss of memory in the record.
Remind the client what day of the week it is.
Notify the family of the change in the client's condition.
Encourage the client to rest during the day.
The Correct Answer is B
A. Documenting the client's loss of memory is important for ongoing assessment, but it is not the immediate action to take when the client is confused about the day of the week.
B. Reminding the client of the day of the week is a direct intervention to help orient the client, which is a primary approach for managing acute confusion or disorientation.
C. Notifying the family of the change in the client’s condition may be necessary if confusion persists or worsens, but initial steps should focus on immediate management of the confusion.
D. Encouraging the client to rest is a general supportive action but does not address the specific issue of confusion about the day of the week.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.
Correct Answer is B
Explanation
A. Eliminating citrus drinks is not specifically related to preventing dumping syndrome. While citrus drinks might irritate the stomach, the main dietary consideration for dumping syndrome is the timing of fluid intake.
B. Consuming fluids 30 minutes to one hour after meals helps prevent dumping syndrome. Drinking fluids too close to meal times can increase the risk of dumping syndrome by accelerating gastric emptying.
C. Increasing the intake of carbonated fluids after meals is not recommended for preventing dumping syndrome. Carbonated drinks can exacerbate symptoms rather than help prevent them.
D. Avoiding caffeinated beverages can be part of general dietary recommendations, but it is not the primary measure to prevent dumping syndrome. The timing of fluid intake relative to meals is more crucial.
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