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
Explanation
A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.
Correct Answer is ["B","C","D"]
Explanation
Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.
Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.
Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.
The other options are not directly related to the immediate decision of administering pain medication:
Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.
A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.
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