During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Keep the client's television on with the volume low
Insert an indwelling urinary catheter to minimize interaction with the client.
Consult the provider regarding administering a mild sedative on a schedule.
Move the client to a room near the nurses' station
The Correct Answer is D
A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Form a committee of staff members to investigate current staffing issues:This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.
B. Provide support to staff members who are resistant to staffing changes:While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.
C. Schedule a staff meeting to present the different options to staff members:While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.
D. Give the staff members advance written notice of staffing changes:Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.
Correct Answer is B
Explanation
A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
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