The nurse is working in a long-term care facility and has been caring for a client for several years
During the morning shift, the client's family appears at the nurse's station stating that their family member has forgotten the family's last visit and has confused their names, even after correcting. The nurse looks at the preceding shift documentation and notes that the staff states that the client is acting odd. Which would be the nurse's first action? A) Call the physician to report a change in client status.
B) Complete a thorough head-to-toe assessment.
C) Medicate as ordered.
D) Obtain a urine sample to be sent to the lab.
B
Feedback:
The nurse's first action is to complete a thorough head-to-toe assessment. The nurse understands that older adults can have delirium as a presenting symptom for infections such as pneumonia or urinary tract infections. Data suggesting an infection can be acquired from a nursing assessment. The physician would not be notified until after an assessment is completed. The nurse would medicate the client as ordered. A physician's order is needed for a urine sample.
You might also like to view...
The nurse is creating interventions for a client that are innovative and different. This nurse is demonstrating critical and creative thinking by:
a. needing to learn each new situation at his own pace. b. following the status quo in order to provide safe care. c. looking to authority figures for the right answers. d. being able to transfer learning from one situation to another.
The client asks the nurse why her health care provider prescribed esomeprazole for her. The nurse's best response is:
a. "This drug is used to treat the inflammation in your esophagus caused by GERD." b. "This drug was prescribed to help neutralize the stomach acid causing your GERD." c. "You really need to ask your doctor why his is treating you with this drug." d. "You can use medications much cheaper that will do the same thing."
The nurse caring for a patient who has tuberculosis and who is taking isoniazid, rifampin, and streptomycin reviews the medical record and notes the patient's sputum cultures reveal resistance to streptomycin
The nurse will anticipate that the provider will take which action? a. Add ethambutol (Myambutol). b. Change the streptomycin to clarithromycin. c. Change the streptomycin to kanamycin. d. Order renal function tests.
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?
A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"