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 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.
Correct Answer is A
Explanation
When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child. Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.
Let's evaluate why the other options are incorrect:
B. Safety plan to keep in a purse at all times:
While a safety plan is essential for individuals experiencing domestic violence, providing a safety plan alone may not address the immediate danger the client is facing. It is crucial to prioritize the client's safety by connecting her with a women's shelter where she can receive comprehensive support.
C. Visit summary documenting the report of abuse:
While it is important to document any reports of abuse, providing a visit summary alone does not address the urgent need for the client's safety. Documentation can be helpful for future reference, but immediate action should be taken to ensure the client's well-being.
D. Paperwork needed to file a restraining order:
Filing a restraining order is a legal step that may be necessary in cases of domestic violence, but it should be pursued after ensuring the client's immediate safety. Providing paperwork alone does not address the client's immediate need for a safe environment. Connecting the client with a women's shelter is a more appropriate course of action to ensure her safety and well-being.
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