A fractured hip in an elderly person can be a life-threatening injury due to the risk of complications such as blood clots, pneumonia, and infection.

It is important for the nurse to assess the man’s pain level, vital signs, and overall condition and initiate appropriate interventions as soon as possible.

Choice A) A client with acute diarrhea may require prompt attention to prevent dehydration, but it is not as urgent as a fractured hip.

Choice B) A client who is anxious may benefit from interventions to reduce anxiety, but it is not a life-threatening condition.

Choice C) A woman who feels isolated may benefit from social support and interventions to address her emotional needs, but it is not an urgent medical condition.

Background noise can interfere with the ability of a person with hearing loss to understand speech, even when wearing a hearing aid.

By turning off the television, the nurse can reduce background noise and improve communication with the client.

Choice A) Chewing gum is not an appropriate intervention to improve communication with a client who has hearing loss.

Choice C) Speaking loudly and clearly may help, but it is not as effective as reducing background noise.

Choice D) Using paper and pencil may be helpful in some situations, but it is not the most effective intervention to improve communication with a client who is wearing a hearing aid.

Collaborate with the client and provider to develop a client-centered plan of care.

It is important for the nurse to respect the client’s cultural and religious beliefs while also ensuring that his medical needs are met.

By collaborating with the client and his healthcare provider, the nurse can help develop a plan of care that takes into account the client’s desire to fast during Ramadan while also managing his diabetes.

Choice A) Educating the client that fasting is not an option is not respectful of the client’s beliefs and may not be effective in promoting adherence to treatment.

Choice B) Telling the client not to take his insulin the night before is not appropriate as it may result in uncontrolled blood sugar levels.

Choice C) Informing the client that he will need to change his lifestyle completely is not a client-centered approach and may not be effective in promoting adherence to treatment.

Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.

This set of vital signs is cause for concern because the blood pressure is significantly elevated.

A blood pressure reading of 196/114 mmHg is considered a hypertensive crisis and requires immediate medical attention.

Choice A) Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg is within normal limits for an adult.

Choice C) Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg is also within normal limits for an adult.

Choice D) Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg is slightly elevated but not cause for immediate concern.

Encouraging bed rest would be an inappropriate nursing intervention to promote mobility for a client with decreased mobility.

Bed rest can lead to further complications of immobility1.

Choice A is not an answer because teaching the client to do active range of motion (AROM) exercises every 2 hours can help maintain joint mobility and muscle strength2.

Choice B is not an answer because evaluating the client’s need for ambulatory aids can help them move safely and independently1.

Choice C is not an answer because keeping skin clean and dry is important for preventing skin breakdown, which can be a complication of immobility1.

Inducing vomiting is not always the appropriate first aid response for poisoning and can sometimes be harmful.

It is important to call the poison control center for guidance on what to do if you suspect poisoning1.

Choice A is not an answer because taking prescription medications only as prescribed can help prevent accidental poisoning1.

Choice B is not an answer because sharing prescription medications can be dangerous and lead to accidental poisoning2.

Choice D is not an answer because having the phone number for the poison control center easily accessible can help you quickly get guidance on what to do in case of suspected poisoning1.

This scenario is an example of cultural imposition.

Cultural imposition is when one person or group imposes their beliefs, values, and practices on another person or group.

Choice B is not an answer because cultural competency involves understanding and respecting the beliefs, values, and practices of different cultures.

Choice C is not an answer because stereotyping involves making assumptions about a person or group based on preconceived notions or generalizations.

Choice D is not an answer because racism involves discrimination or prejudice against a person or group based on their race.

Pressure injuries may be a result of decreased mobility.

When a person has decreased mobility, they may spend extended periods of time in one position, which can put pressure on certain areas of the body and lead to the development of pressure injuries.

Choice B is not an answer because diarrhea is not typically a result of decreased mobility.

Choice C is not an answer because euphoria is not typically a result of decreased mobility.

Choice D is not an answer because increased energy is not typically a result of decreased mobility.

The primary purpose of an incident report is to identify opportunities for improvement.

Incident reports are used to document and analyze events that have occurred in order to identify areas for improvement and prevent similar incidents from happening in the future.

Choice A is not an answer because incident reports are not typically used as a tool for disciplinary action.

Choice B is not an answer because while incident reports can help identify and address errors, their primary purpose is not to eliminate unforeseen errors.

Choice D is not an answer because the primary purpose of incident reports is not to hold persons accountable for their errors, but rather to identify opportunities for improvement.

According to Maslow’s Hierarchy of Needs, all people have basic human needs that must be met before they can attend to higher needs.

These basic human needs are physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization1.

Choice A is incorrect because people do not have the same needs at the same time.

Choice B is incorrect because Maslow’s Hierarchy of Needs does not mention the risk of becoming ill.

Choice C is incorrect because not all people have a desire to be the best.