An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention should the PN implement?
Delay administration of nighttime medications until after visitors have left.
Administer a prescribed PRN benzodiazepine at the onset of a confused state.
Make certain that the client's assigned room is close to the nurses' station.
Ask family members about how they dealt with the client in the evening.
The Correct Answer is C
Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The first action the PN should take is to check the client's serum human chorionic gonadotropin (hCG) level. This hormone is produced by the placenta and can provide important information about the viability of the pregnancy.
Option B, verifying the date of the last menstrual cycle, can provide useful information about the gestational age of the pregnancy but is not the first priority.
Option C, repeating a urine pregnancy test, can confirm the presence of a pregnancy but does not provide information about its viability.
Option D, inquiring about the last occurrence of intercourse, is not relevant to addressing the client's immediate concern of vaginal bleeding.
Correct Answer is B
Explanation
The information that poses the greatest risk for developing postpartum endometritis in this situation is that the client experienced spontaneous rupture of membranes (SROM) for 36 hours prior to delivery. SROM for an extended period of time increases the risk of infection, including postpartum endometritis, which is an infection of the uterus. The practical nurse (PN) should recognize this risk factor and monitor the client closely for signs of infection. The other information listed may also be important to consider, but SROM for 36 hours poses the greatest risk for developing postpartum endometritis in this situation.
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