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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Baclofen is a muscle relaxant that can help relieve muscle spasms and manage conditions such as cerebral palsy¹. An assessment finding that indicates the drug is effective for a child with cerebral palsy would be decreased muscular spasticity. This means that the child's muscles are less stiff and rigid, which can improve their mobility and overall quality of life.
The other choices are incorrect because they are not directly related to the therapeutic effects of baclofen. Baclofen is a muscle relaxant that is used to relieve muscle spasms and stiffness. While it may have other effects on the body, its primary therapeutic effect is to decrease muscular spasticity.
- Increased appetite is not a known effect of baclofen.
- Sufficient urinary output is important for overall health, but it is not directly related to the effectiveness of baclofen.
- Fewer temper outbursts may be an indirect result of decreased muscular spasticity and improved mobility, but it is not a direct effect of baclofen.
Correct Answer is B
Explanation
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
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