At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes that someone is standing behind the privacy curtain. Which action should the practical nurse (PN) take?

Administer a PRN antianxiety agent.

Tell her no one is behind the curtain.

Transfer the client to another room.

Leave a night light on in her room.

Answer and Explanation

The Correct Answer is D

A.   Administer a PRN antianxiety agent. - This should be a last resort due to potential side effects.
Non-pharmacological interventions are usually preferable.
B.   Tell her no one is behind the curtain. - Arguing or contradicting her belief may escalate her agitation or confusion.
C.   Transfer the client to another room. - Moving her to a new environment might exacerbate her confusion and distress.
D.   Leave a night light on in her room. - This is a simple, non-intrusive intervention that can help reduce visual misinterpretations and provide comfort, potentially calming her agitation without confrontation or disruption.

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Correct Answer is D

Explanation

A. Including guidelines for coping in the discharge plan might be important but doesn’t address the immediate concern of the client having access to a potential means of self-harm.
B. Calling dietary for plastic utensils might help remove the immediate risk of harm, but informing the healthcare provider takes priority.
C. Informing the family is essential for support but doesn’t directly address the current risk.
D. Informing the healthcare provider who discharged the client is crucial as they need to reassess the discharge plan in light of the client's current statement and remove the potential means of self-harm.

A. A Irrigate an indwelling urinary catheter for a client with bladder suspension. B. Empty bedside drainage unit for a client with indwelling urinary catheter. C. Transport a urine culture sample to the laboratory. D. Obtain a post-voided residual (PVR) volume.

Correct Answer is ["B","C","D"]

Explanation

A. Irrigate an indwelling urinary catheter for a client with bladder suspension. - This procedure requires specialized skills and should be performed by a licensed nurse.
B. Empty bedside drainage unit for a client with an indwelling urinary catheter. - UAP can safely perform this task by following established protocols to maintain catheter hygiene.
C. Transport a urine culture sample to the laboratory. - This task involves safely transporting a specimen and does not require specialized medical knowledge.
D. Obtain a post-voided residual (PVR) volume. - This task can be performed by UAP under supervision or with appropriate training, using a bladder scanner or assisting the client to measure remaining urine.
E. Teach the client with fluid restrictions how to measure urine output. - Teaching tasks generally fall under the responsibility of licensed nursing staff and may require specific medical knowledge.

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At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes that someone is standing behind the privacy curtain. Which action should the practical nurse (PN) take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client who is scheduled to be discharged within several hours shows the practical nurse (PN) a knife on her tray and states that she could use it to cut herself. What intervention is most important for the PN to implement?

Correct Answer is D

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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