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 D
Explanation
A) Incorrect- This response might address the client's concern but doesn't directly address her dichotomous thinking or provide immediate therapeutic communication.
B) Incorrect- While showing happiness for the client's improvement is positive, this response does not address the client's behavior or engage with her dichotomous tendency.
C) Incorrect- This response acknowledges the client's liking but doesn't address the dichotomous thinking pattern or provide an effective therapeutic response.
D) Correct- answering this question encourages the client to express her concerns and perceptions, fostering communication. This approach acknowledges the client's feelings and provides an opportunity for her to discuss the issue, potentially leading to a productive conversation.
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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