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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Keeping the battery door closed during storage is generally a good practice to prevent battery drain; however, it may be more appropriate to keep it open for extended storage to avoid moisture buildup. The PN should clarify proper storage practices.
B. Observing and reporting any ear drainage after removing the device is crucial. Any drainage could indicate an infection or other issues that require further evaluation by nursing staff.
C. Storing the device on a windowsill is not advisable, as this increases the risk of loss or damage. A secure, designated storage area is better for such items.
D. Verifying that the device is labeled with the client's identification is important to prevent mix-ups and ensure proper usage. Proper labeling aids in maintaining accountability and safety in a long-term care setting.
E. Removing ear wax from the device's surface is appropriate as it ensures the hearing aid functions properly and maintains hygiene.
Correct Answer is A
Explanation
This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.
The other options are not correct because:
B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.
C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.
D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.
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