An older female client is admited to the orthopedic unit following surgical repair of a fractured hip. On the second postoperative day, the client becomes confused and repeatedly asks the practical nurse (PN) where she is. Which information should the PN obtain before reporting to the charge nurse?
Current administration of analgesics or antianxiety medications.
History of situational depression related to major life events.
Previous episodes of frequent falls.
The client's history of alcohol abuse.
The Correct Answer is A
The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.
Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.
Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.
Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first action the PN should take is to obtain a point-of-care glucose test. This will provide immediate information about the patient's blood sugar level and help guide further interventions.
Option A, reviewing prior insulin prescriptions, is important but not the first priority.
Option B, checking blood pressure, is also important but not the most immediate concern.
Option D, assessing urine for ketones, can provide useful information about the presence of ketones in the urine, which can indicate diabetic ketoacidosis, but it is not the first action that should be taken.
Correct Answer is C
Explanation
A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.
The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a different issue.
The presence of an infectious blood-borne disease cannot be determined from this test.
The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.
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