A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?

Advise the UAP to resume positioning the client on schedule.

Encourage the UAP to provide comfort care measures only.

Assume total care of the client to monitor neurologic function.

Assign a practical nurse to assist the UAP in turning the client.

Answer and Explanation

The Correct Answer is A

Choice A: Advise the UAP to resume positioning the client on schedule.

Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.

Choice B: Encourage the UAP to provide comfort care measures only.

Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.

Choice C: Assume total care of the client to monitor neurologic function.

Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.

Choice D: Assign a practical nurse to assist the UAP in turning the client.

Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Mild sedation is a common and expected side effect of ramelteon, which is a sedative used to treat insomnia. It is generally not a cause for concern unless it persists or worsens.

Choice B reason: Dizziness reported after the initial dose is also a common side effect of ramelteon. It usually diminishes as the body adjusts to the medication. However, if dizziness persists or is severe, it should be reported to the healthcare provider.

Choice C reason: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.

Choice D reason: A change in the sleep-wake cycle is an expected effect of ramelteon, as it is used to manage the sleep-wake cycle in people with insomnia. It is not typically a side effect that needs to be reported unless the changes are extreme or cause significant distress.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Choice A Reason: Decreasing portion sizes can help manage calorie intake and contribute to weight loss, which is beneficial for individuals with prediabetes or diabetes. Proper portion control is also essential for maintaining blood sugar levels within the target range.
Choice B Reason: Avoiding potassium-rich foods is not a standard dietary recommendation for diabetes management unless the individual has a specific condition like kidney disease that requires potassium restriction.
Choice C Reason: Eating only plant-based foods is not necessary for diabetes management. While a plant-based diet can be part of a healthy eating plan, it is not required for all individuals with diabetes.
Choice D Reason: Choosing a well-rounded diet ensures that all necessary nutrients are included, which is important for overall health and can help manage blood sugar levels. A balanced diet for diabetes should include a variety of foods from all food groups.
Choice E Reason: Eliminating carbohydrates is not recommended for diabetes management. Carbohydrates are a necessary part of a healthy diet, and individuals with diabetes should focus on the type and amount of carbohydrates consumed rather than eliminating them entirely.
Choice F Reason: Replacing refined sugar with honey or molasses is not necessarily beneficial for diabetes management. While these are natural sweeteners, they still affect blood sugar levels and should be used in moderation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

Patient Data Exhibits Review H and P and laboratory results. Drag from the Word Choices to complete the sentence. For the nutrition education portion of the visit, the nurse focuses on dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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