An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Document the client's loss of memory in the record.

Notify the family of the change in the client's condition.

Remind the client what day of the week it is.

Encourage the client to rest during the day.

Answer and Explanation

The Correct Answer is C

it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.

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Correct Answer is A

Explanation

This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can aﬀect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.

A. Obtain emergency help. B. Feel for a carotid pulse. C. Bring a glucometer to the room. D. Check the blood pressure.

Correct Answer is A

Explanation

A. Obtain emergency help. - This is the most urgent action as the client is unresponsive, and getting emergency assistance is crucial to providing immediate care.
B. Feel for a carotid pulse. - While assessing the pulse is important, if the client is unresponsive, the first step is to get emergency assistance.
C. Bring a glucometer to the room. - This action might be relevant for assessing specific conditions, but in this scenario, the priority is to seek immediate emergency assistance.
D. Check the blood pressure. - Assessing blood pressure is important, but in the case of an unresponsive client, seeking emergency help takes precedence for immediate assistance and care.

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An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

Correct Answer is A

Explanation

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Correct Answer is A

Explanation

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

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A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

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