The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

Raise the four side rails on the bed.

Close the client's room door.

Orient the client to the surroundings.

Secure a bed alarm on the mattress.

Escort the client back to her room.

Answer and Explanation

Correct Answer : C,D,E

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

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Correct Answer is A

Explanation

A. Acknowledging that this is a difficult time for the mother is empathetic and supportive. It provides an opportunity for the mother to express her feelings and concerns without placing blame, which can be helpful in managing emotional distress.
B. While reassuring the mother that she did nothing wrong is important, it does not fully address her emotional needs or allow her to express her feelings. It may be perceived as dismissive if not accompanied by empathy.
C. Reassuring the mother about the outcome of surgery is important, but it does not address the emotional impact of her feelings of guilt or responsibility.
D. Asking why the mother thinks it is her fault may not be as supportive or helpful as providing empathy and reassurance. It could potentially lead to further distress rather than addressing the emotional support she needs.

A. Develop a plan for gradually increasing activity and mobility. B. Begin discharge planning and teaching. C. Implement precautions to prevent disease transmission. D. Offer the client frequent fluids and ice chips.

Correct Answer is C

Explanation

A. Developing a plan for increasing activity and mobility is important but is not the immediate priority during the prodromal stage of an infection.
B. Discharge planning and teaching are relevant for patient management but not the priority during the early stages of infection.
C. Implementing precautions to prevent disease transmission is crucial during the prodromal stage, as this is when the infection may be most contagious. Preventing the spread of infection is the top priority.
D. Offering fluids and ice chips helps with comfort and hydration but does not address the prevention of disease transmission.

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The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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