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
A) Correct - Acute dystonic reactions are involuntary muscle spasms caused by certain medications, including antipsychotic drugs. These reactions can sometimes affect the muscles of the face and neck, including the larynx. Benztropine is an anticholinergic medication commonly used to treat acute dystonic reactions. It works by blocking certain neurotransmitters that contribute to muscle spasms, helping to relieve the symptoms.
B) Incorrect - Divalproex is an anticonvulsant medication primarily used to treat epilepsy and bipolar disorder. It is not the appropriate treatment for acute dystonic reactions. These reactions are usually caused by certain antipsychotic medications and are characterized by sudden and involuntary muscle contractions. Divalproex does not have the specific mechanism of action needed to alleviate the symptoms of acute dystonic reactions.
C) Incorrect - Isotonic crystalloid fluids are used for various purposes, such as fluid resuscitation, maintaining hydration, and balancing electrolytes. However, they are not a treatment for acute dystonic reactions. These reactions are neurological and musculoskeletal in nature and require medications with specific anticholinergic properties, like benztropine, to address the underlying issue.
D) Incorrect - Lorazepam is a benzodiazepine commonly used for anxiety, sedation, and seizure control. While it can have a relaxing effect on muscles, it is not the first-line treatment for acute dystonic reactions. Anticholinergic medications like benztropine are more appropriate because they directly counteract the neurotransmitter imbalances that lead to muscle spasms in these reactions.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today