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.
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Related Questions
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
Correct Answer is B
Explanation
This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.
Encouraging the client to be calm and relax for a little while (A) may not be effective in managing the compulsive behavior.
Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately effective in managing the client's behavior in the moment.
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