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
One of the most important interventions in caring for clients with major depressive disorder is building a therapeutic relationship. Scheduling regular periods of time for interaction with the client demonstrates support and provides an opportunity for the client to express their feelings and concerns. Journaling and self-reflection can be helpful interventions for some clients, but they do not necessarily demonstrate support.
Assisting the client to identify symptoms of depression is important for assessment and care planning, but it is not a way to demonstrate support.
Incorporating animated communication techniques may be appropriate for certain clients, but it is not a universal intervention for supporting clients with major depressive disorder.
Correct Answer is C
Explanation
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
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