An older adult female client is admited to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening, the client becomes restless, confused, and agitated.
Which instruction should the PN provide to the unlicensed assistive personnel who is assisting in the care of the client?
Calmly offer to walk around the hallways with the client.
Make sure the room lights are dimmed to calm the client.
Leave the client alone until signs of agitation have passed.
Measure the client's vital signs at the onset of agitation.
The Correct Answer is A
Restlessness, confusion, and agitation in the evening are common symptoms of sundowning, which is a condition that affects some older adults with dementia. Offering to walk around the hallways with the client can provide a calming effect and reduce the symptoms of sundowning.
Dimming the lights may actually increase confusion and agitation, and leaving the client alone may increase feelings of isolation and fear.
Measuring the client's vital signs may not be necessary unless there are specific medical concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.
Correct Answer is B
Explanation
This finding may indicate a potential cardiac issue that needs immediate medical atention. Projectile vomiting and excessive hunger in a young infant may be signs of pyloric stenosis, a condition in which the muscle between the stomach and small intestine thickens, making it difficult for food to pass through.
Hyperactive gastric sounds may be present with vomiting, but it is not an immediate concern.
Crying without tears may be a sign of dehydration, but it is not an immediate concern.
Underweight for age is a concern but it is not a finding that requires immediate intervention.
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