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
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Correct Answer is D
Explanation
A. Ineffective pain management reported while using morphine PCA is concerning but may not be immediately life-threatening.
B. Inability to void after discontinuing an indwelling catheter should be addressed but might not require immediate attention.
C. Oral ice chips eaten after vomiting postoperatively might need monitoring, but it's not typically an urgent issue.
D. Coffee-ground secretions draining via nasogastric tube suction could indicate bleeding in the upper gastrointestinal tract, which requires immediate attention due to the potential for severe
bleeding.
Correct Answer is C
Explanation
A. Obliterating the entry could make the record look messy and might not meet documentation standards.
B. Notifying the charge nurse might be appropriate for major errors or if the policy requires it, but it might not be necessary for a simple correction like this.
C. Drawing a single line through the erroneous entry and inserting the correct information maintains the integrity of the chart and shows the correction clearly.
D. Charting the correct information in the next column might create confusion about the sequence of data and might not clearly indicate the correction made.
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