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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- Choice A: No Understanding
- Reason: An echocardiogram is a non-invasive procedure that uses ultrasound waves to create images of the heart.
- Choice B: Understanding
- Reason: Parents can indeed show their child a movie or read a book during the procedure as it helps keep the child calm and still, which is conducive for a transthoracic echocardiogram².
- Choice C: No Understanding
- Reason: An echocardiogram is generally not a painful procedure. It is non-invasive and involves placing a transducer on the chest to capture images of the heart².
- Choice D: Understanding
- Reason: The echocardiogram will indeed produce an image of the structure of the heart, which is essential for diagnosing and assessing conditions like VSD.
- Choice E: Understanding
- Reason: Echocardiography uses sound waves to produce images of the heart, which can show how well blood is moving through the heart and heart valves.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.
Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.
Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.
Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.
Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.
Normal Ranges:
- BMI: 18.5 to 24.9 kg/m² (normal)
- HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
- LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
- Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)
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