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.
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Related Questions
Correct Answer is C
Explanation
This is the best action for the PN to take because it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
Correct Answer is A
Explanation
The correct answer is Choice A:
"Determine home navigational safety hazards.”. Choice A rationale:
The PN should first assess the client's home for safety hazards that may be contributing to the client's unsteadiness and increased fall risk. Identifying and addressing these hazards can help create a safer environment for the client and potentially prevent accidents.
Choice B rationale:
Encouraging the client to obtain a medical alert device is not the immediate priority in this situation. Addressing the client's safety and identifying potential hazards should be the first step before considering additional measures like medical alert devices.
Choice C rationale:
Recommending that the client obtain a walker is premature without first assessing the home
environment and determining if there are any correctable safety issues. The PN should prioritize safety assessment before recommending any assistive devices.
Choice D rationale:
While maintaining the client's privacy is important, it is not the most urgent action in this scenario. The priority is to assess the client's safety and identify potential hazards in the home. Privacy concerns can be addressed afterward.
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