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.
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Related Questions
Correct Answer is C
Explanation
A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.
Correct Answer is B
Explanation
A. Placing a biohazard bag over the basin and sealing it is not appropriate because the specimen should have been collected directly into a sterile container, and the specimen's current state in a non-sterile basin is not acceptable for lab analysis.
B. Assisting the client in obtaining another specimen is necessary to avoid cross contamination.
C. Using a wooden applicator to place the sputum specimen in a sterile container is the incorrect as it breaches sterility.
D. Applying gloves and placing the tissue and specimen in a container is incorrect as the specimen must be in a sterile container from the start. Using a non-sterile basin means the specimen might be contaminated.
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