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 {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Applicable
Evaluating functional improvement assesses whether the additional physical and occupational therapy is effectively enhancing the client’s ability to perform activities of daily living and participate in community activities. This focuses on tangible outcomes of the therapy, such as improved mobility or independence. Measuring functional improvement helps to determine if the interventions are meeting their goals and positively impacting the client's physical abilities.
Psychological assessment
Not Applicable
While important, psychological assessment is not the primary focus when evaluating the specific outcomes of physical and occupational therapy. Psychological well-being might be a component of overall care but is not the immediate measure for the success of the physical therapies established. The main goal here is to assess the effectiveness of the physical and occupational therapy, which is more directly measured by functional and quality of life improvements.
Quality of life
Applicable
Assessing quality of life evaluates how well the client’s overall well-being is supported by the new care interventions, including their physical comfort, mental health, and ability to engage in daily activities. This broader measure considers whether the care provided enhances the client's satisfaction with their daily life and personal experiences, reflecting the success of the implemented therapies.
Financial security
Not Applicable
Financial security is not directly related to evaluating the outcomes of physical and occupational therapy interventions. It is important for overall care management but does not measure the effectiveness of specific therapies or the impact on the client’s physical functioning or quality of life. This factor is outside the scope of assessing the direct results of therapy and daily living support.
Cognitive status
Not Applicable
Cognitive status is not the main focus for evaluating the success of physical and occupational therapy. While cognitive status is relevant for overall care, the immediate goal of assessing the effectiveness of the physical therapies is to see improvements in functional abilities and quality of life. Cognitive assessments are important but not directly related to the specific goals of physical and occupational therapy outcomes
Correct Answer is C,A,B,D
Explanation
Rationale
1. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.
2. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.
3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.
4. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.
5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently
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