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 ["0.6"]
Explanation
- Medication dose: 30 mg enoxaparin
- Medication concentration: 30 mg per 0.3 mL (prefilled syringe)
- Frequency: Every 12 hours
- Duration: 10 days
Calculation:
- Injections per day: Since the medication is given every 12 hours, the client will receive injections 2 times per day (24 hours / 12 hours/injection).
- Total medication per day: To find the total amount of enoxaparin needed per day, multiply the single injection dose by the number of injections:
Total enoxaparin/day = Dose per injection x Number of injections/day = 30 mg/injection x 2 injections/day = 60 mg/day
- Volume of medication per day: Now, we need to find the volume of solution needed to deliver the total daily dose (60 mg) based on the medication concentration (30 mg/0.3 mL). We can achieve this with a proportion:
Volume (mL) / Total dose (mg) = Concentration (mg/mL)
Volume (mL) = (Total dose (mg) x Concentration (mL/mg)) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = (60 mg x 0.3 mL/mg) / 30 mg/mL
Volume (mL) = 18 mL / 30 mL/mL
Simplifying:
Volume (mL) = 0.6 mL
Therefore, the practical nurse (PN) should administer 0.6 mL of enoxaparin each day.
Correct Answer is B
Explanation
A. Understanding that prostate cancer mostly affects older men reflects awareness but does not necessarily indicate acceptance of the prognosis.
B. Expressing that the client has found support from faith and family and rejecting negative outlooks shows a level of emotional acceptance and coping with the reality of advanced cancer.
C. Believing that the disease was undetected for a long time suggests denial or frustration rather than acceptance of the prognosis.
D. A desire to try every possible treatment reflects hope and possibly denial rather than acceptance of the prognosis.
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