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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Administer a PRN antianxiety agent. - This should be a last resort due to potential side effects.
Non-pharmacological interventions are usually preferable.
B. Tell her no one is behind the curtain. - Arguing or contradicting her belief may escalate her agitation or confusion.
C. Transfer the client to another room. - Moving her to a new environment might exacerbate her confusion and distress.
D. Leave a night light on in her room. - This is a simple, non-intrusive intervention that can help reduce visual misinterpretations and provide comfort, potentially calming her agitation without confrontation or disruption.

A. Determine the means by which residents will be evacuated. B. Close all fire doors and the doors to all the residents' rooms. C. Assist any wandering residents back to their rooms. D. Offer comfort and reassurance to distraught residents.

Correct Answer is A

Explanation

A. Determining the means of evacuation requires understanding the facility's evacuation protocols, coordinating with authorities, and ensuring the safety of residents, which typically falls under the responsibility of the nursing staff, including the practical nurse (PN).
B. Closing fire doors and residents' room doors can be part of fire safety protocols and may involve the immediate safety response handled by both nursing staff and facility personnel.
C. Assisting wandering residents and offering comfort and reassurance to distraught residents can be tasks shared among nursing and support staff to ensure resident safety and well-being during an emergency situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes that someone is standing behind the privacy curtain. Which action should the practical nurse (PN) take?

Correct Answer is D

Explanation

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

A female client who is scheduled to be discharged within several hours shows the practical nurse (PN) a knife on her tray and states that she could use it to cut herself. What intervention is most important for the PN to implement?

The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best nursing action?

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicense assistive personnel (UAP)?

A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?