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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

An 82-year-old client with Alzheimer's disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.

A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.

A 34-year-old admitted today after an emergency appendectomy who has a PIV and indwelling urinary catheter.

A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline lock PIV.

Answer and Explanation

The Correct Answer is A

A. The combination of cognitive impairment, physical injury, and restraints poses a high risk for complications such as infection, skin breakdown, and falls. Close monitoring and nursing interventions are critical to ensure safety, comfort, and appropriate care in this patient.

B. While this client may need some care for the electrolyte imbalance and nausea, this situation is more stable compared to the elderly client with Alzheimer's. The RN's role here would focus on managing the electrolyte disturbance and providing symptom relief.

C. Although this client is postoperative and may need some care, the RN's focus would primarily be on pain management and monitoring for infection or complications. However, the client’s condition is relatively stable compared to the elderly client with multiple risks.

D. This client is also stable and may require some ongoing monitoring for respiratory issues. However, the level of care needed is less intensive compared to a client with cognitive issues, restraints, and a recent fracture.

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Correct Answer is C

Explanation

A. Suggest to the client that he take a walk: Allowing pacing might escalate the agitation or delusions, especially in a stimulating environment. This does not address the immediate need to reduce stimuli.

B. Use firmness and direct the client to sit for a while: Direct commands may increase the client's agitation or trigger a confrontation if the client feels threatened or challenged while delusional.

C. Move the client to a quiet place on the unit: Reducing environmental stimuli by relocating the client to a low-stimulation setting can help de-escalate the situation and prevent further loss of control.

D. Encourage the client to use the punching bag: Promoting physical aggression even if directed at an object may reinforce violent behavior and is inappropriate during acute delusional episodes.

A. Ask family members to remain with the client in the evenings from 1700 to 2100. B. Administer a prescribed PRN benzodiazepine at the onset of a confused state. C. Postpone administration of nighttime medications until after 2300. D. Ensure that the client is assigned to a room close to the nurses' station.

Correct Answer is D

Explanation

A. Ask family members to remain with the client in the evenings from 1700 to 2100: While family presence can offer comfort, it is not always feasible and doesn’t directly address the environmental management needed for sundowning behaviors.

B. Administer a prescribed PRN benzodiazepine at the onset of a confused state: Though medications may help in acute cases, routine pharmacologic management is not the first-line intervention due to risks like oversedation and increased fall risk in older adults.

C. Postpone administration of nighttime medications until after 2300: Delaying medications may interfere with sleep hygiene and the efficacy of routine medications that aid in rest or symptom management.

D. Ensure that the client is assigned to a room close to the nurses' station: Proximity to staff allows for more frequent monitoring and faster intervention during episodes of confusion, helping prevent injury and manage behaviors associated with sundowning.

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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

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Naxlex Comprehensive Predictor Exams

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notices that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

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