An older female adult who was admitted 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?

The correct answer is choice C. Assign the remainder of medication administration to another PN who is performing treatments.

Choice A rationale:

Asking unlicensed assistive personnel (UAP) to give medications to their assigned residents is not the best action to take in this situation. Medication administration requires a certain level of training and knowledge to ensure safe and accurate delivery. UAPs may not have the appropriate training and legal authorization to administer medications, which could lead to potential errors and harm to the residents.

Choice B rationale:

Documenting why all the medications were not given to each resident is not sufficient to address the issue at hand. While documentation is essential for record-keeping and communication, it does not resolve the problem of medication administration being left incomplete. The priority should be finding a qualified person to administer the remaining medications.

Choice C rationale:

This is the correct answer because assigning the remainder of medication administration to another PN who is performing treatments ensures that qualified and trained personnel are handling the medication administration. This PN is likely familiar with medication protocols and safety measures, reducing the risk of errors.

Choice D rationale:

Denying the medication aide's request to leave before all medications are given might not be practical if the aide is genuinely unwell or unable to continue working safely. The focus should be on ensuring that medication administration is completed by qualified staff rather than forcing the sick aide to stay.

The correct answer is Choice A:

"Are you planning to obey the voices?.”. Choice A rationale:

The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.

Choice B rationale:

While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.

Choice C rationale:

Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.

Choice D rationale:

Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.