During the past 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse (PN) take?
Record the findings and report the symptoms to the charge nurse
Ask the family members to visit more often to stimulate the client
Motivate the client by offering favorite foods as a prize
Withhold any medications that may cause these side effects
The Correct Answer is A
The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.
Choice A rationale:
The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.
Choice B rationale:
Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.
Choice C rationale:
Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.
Choice D rationale:
Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.
C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.
D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.
Correct Answer is A
Explanation
The correct answer is choice A: Never scratch under the cast.
Choice A rationale:
It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.
Choice B rationale:
While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.
Choice C rationale:
Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.
Choice D rationale:
Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.
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