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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing the client's mental status is crucial before administering zolpidem, a sleep aid, as it helps ensure the client is alert enough to take the medication safely. This assessment includes evaluating the client's level of consciousness, orientation, and cognitive function.
B. Monitoring body temperature might be necessary in certain clinical situations, but it's not directly relevant before administering zolpidem unless there are specific concerns related to body temperature.
C. Assessing bowel sounds is an important part of a comprehensive physical assessment, but it's not directly tied to the administration of a sleep aid like zolpidem.
D. Evaluating skin integrity is important for overall patient care, but it's not specifically linked to the assessment needed before administering a sleep medication like zolpidem.
Correct Answer is C
Explanation
A. Evaluating a client's understanding of discharge instructions typically requires a nursing assessment and explanation, more suitable for a licensed nurse.
B. Encouraging fluid intake might involve assessing the client's condition and providing specific advice, which aligns more with the responsibilities of a licensed nurse.
C. Measuring urinary output is a task that falls within the scope of practice for unlicensed assistive personnel (UAP), as it involves routine data collection and does not require clinical judgment.
D. Checking a client's femoral dressing after a cardiac catheterization requires observation for signs of bleeding, which involves assessment and potential interventions beyond the UAP's scope of practice.
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