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The nurse provides care for an older adult client who appears fully alert and
oriented. As it gets later in the day, the nurse notices the client becoming
increasingly confused and agitated. It would be *most* appropriate for the nurse to
take which of these actions?
A. Reorient the client, and then turn on the lights and television to distract the
client from his confusion
B. Encourage the client's alert roommate to talk with the client
C. Tell the client he is at home in his own bed to get him to settle down and go to
sleep
D. Reorient the client, pull the shades down, shut the lights and television off, and
promote a quiet environment - 🧠ANSWER ✔✔D. Reorient the client, pull the
shades down, shut the lights and television off, and promote a quiet environment
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,Rationale: Promoting a quiet environment decreases stimulation to prevent
agitation. it also promotes the normal sleep-wake cycle, consistent with it being
"later in the day."
The nurse cares for a client who will undergo a mastectomy in the morning. A call
from the front desk alerts the nurse that the client's family has arrived. It would be
*most* appropriate for the nurse to take which of these actions?
A. Tell the family that they cannot come in because visiting hour are over
B. Tell the client you want to make sure she has some alone time to relax
C. Invite the family in to offer support after confirming with the client
D. Tell the unlicensed assistive personnel (UAP) to sit with the client who needs
company - 🧠ANSWER ✔✔C. Invite the family in to offer support after confirming
with the client
Rationale: During time of stress and anxiety, such as undergoing surgery, nurses
should promote family support. The answer choice also states that the nurse would
ask the client first. This supports including clients in their care.
The nurse cares for the male client who has expressed a desire to commit suicide.
He has informed the nurse of plans to pursue this. The nurse requests a sitter to
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, stay with the client around the clock, but the client says he does not want this.
Which of these is the *most* appropriate responses by the nurse?
A. The nurse allows the young man to refuse, because clients do have a right to
refuse care
B. The nurse implements the intervention, because protecting the client's safety
overrules the client's right to refuse care
C. The nurse checks on the client every hour to be sure he is safe and the sitter is
fine
D. The nurse asks the unlicensed assistive personnel (UAP) to check on the client
every 30 minutes to be sure he is safe - 🧠ANSWER ✔✔B. The nurse implements
the intervention, because protecting the client's safety overrules the client's right to
refuse care
Rationale: Protecting the client's safety trumps the client's right to refuse care.
A client scheduled to have surgery tells the nurse, "I'm very scared. I have never
had surgery before and am afraid that I might not make it through." Which
response by the nurse is *best*?
A. "Why do you feel this way?"
COPYRIGHT©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
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