The practical nurse (PN) reorients a male client to the correct time, day, date, location, and why he is here today but he is only able to remember his name and where he is. Based on these findings, what should the PN document?
Oriented x 3.
Oriented x 1.
Oriented x 2.
Oriented x 4.
The Correct Answer is C
A. Oriented x 3. - The client must recall the time, day, date, location, and reason for being there to be considered oriented x 3. As the client can only remember his name and location, it does not fulfill the criteria for oriented x 3.
B. Oriented x 1. - This is inaccurate as the patient is oriented in two aspects: person and place.
C. Oriented x 2. - The client recalls their name and place, hence is oriented in two aspects. This is therefore accurate.
D. Oriented x 4. - This would require the client to recall all four aspects of orientation (time, day, date, location, and reason for being there), which the client did not demonstrate in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Trying not to listen to the conversation does not address the issue of confidentiality breach or protect the client's privacy.
B. Writing an incident report might be necessary, but the immediate action should be to stop the conversation to protect the client's confidentiality.
C. Approaching the individuals involved and asking them to stop is the most appropriate and immediate action to protect the client's privacy and confidentiality.
D. Telling the client about the UAP's concern might not be suitable without context or proper consent, and it might not address the confidentiality breach.
Correct Answer is D
Explanation
A. Birth, 2 months, 12 months, and boosters every 7 to 10 years. - This schedule doesn't align with the typical whooping cough vaccination schedule.
B. 1, 6, 9 months, and boosters at 12 months of age and before entering school. - This schedule doesn't match the typical whooping cough vaccination schedule.
C. 1 year of age, 6 years of age, and with each exposure. - This schedule doesn't align with the standard vaccination recommendations for whooping cough.
D. 2, 4, 6 months, and boosters at 15 to 18 months and 4 to 6 years of age. - This schedule aligns with the recommended vaccination schedule for whooping cough by the CDC, providing primary vaccinations at 2, 4, and 6 months and booster doses later in childhood.
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