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. Elevated energy level: While cocaine use can initially cause increased energy, this is a temporary effect. The most consistent and concerning behavioral manifestation is drug-seeking behavior due to intense cravings.
B. Powerful craving for more: Cocaine is highly addictive and stimulates the brain's reward system, leading to a powerful and often uncontrollable craving for more of the drug, which is a hallmark of cocaine dependence.
C. High self-esteem: Cocaine use may cause temporary grandiosity, but it does not result in true or stable high self-esteem. Users often experience mood swings and depressive symptoms after the drug wears off.
D. Euphoria: Cocaine does cause euphoria, but it is short-lived. The craving for more, even after the initial high, is more defining and persistent in clients who test positive and are in the cycle of use.
Correct Answer is D
Explanation
Choice A: A double turn or square knot is not recommended because it is not a quick-release knot, which is necessary for patient safety in case of an emergency
Choice B: While restraints need to be secure, they should not be snug against the client's wrists. There should be enough space to fit two fingers between the restraint and the wrist to prevent circulation issues.
Choice C: Ties should not be secured to side rails as this can cause injury if the rails are moved. Instead, they should be attached to the movable part of the bed frame.
Choice D: This is the correct action. A half-bow knot is a type of quick-release knot, which is essential for the safety and quick release of the patient if needed
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