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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Obtain emergency help. - This is the most urgent action as the client is unresponsive, and getting emergency assistance is crucial to providing immediate care.
B. Feel for a carotid pulse. - While assessing the pulse is important, if the client is unresponsive, the first step is to get emergency assistance.
C. Bring a glucometer to the room. - This action might be relevant for assessing specific conditions, but in this scenario, the priority is to seek immediate emergency assistance.
D. Check the blood pressure. - Assessing blood pressure is important, but in the case of an unresponsive client, seeking emergency help takes precedence for immediate assistance and care.

A. Administer a prescribed narcotic antagonist to reverse the eﬀects of any analgesic accumulation B. Notify the healthcare provider and request a prescription for restraints to minimize the client's danger to self. C. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative D. Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.

Correct Answer is C

Explanation

The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.

Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.

Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.

Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.

Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Correct Answer is A

Explanation

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Correct Answer is C

Explanation

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

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