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?
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
This is the best action for the PN to take because 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.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
A. Asking another UAP to help the oriented may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
B. Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
C. Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
Correct Answer is A
Explanation
The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show.
Choice A rationale:
The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon.
Choice B rationale:
Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client.
Choice C rationale:
Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided.
Choice D rationale:
Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.
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