A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Placing the client in an orthopneic position is correct. The orthopneic position (sitting upright and leaning forward. helps clients with COPD breathe more easily by maximizing lung expansion and easing the work of breathing. This position is often used in clients with chronic respiratory conditions to alleviate dyspnea.

B. Providing the client with three large meals is incorrect. Clients with COPD may have difficulty eating large meals because it can interfere with breathing due to increased diaphragm pressure. Instead, small, frequent meals are recommended to reduce the workload on the respiratory system.

C. Encouraging the client to cough and deep breathe once every 8 hr is incorrect. In clients with COPD, frequent coughing and deep breathing exercises are important to promote airway clearance and lung expansion. The nurse should encourage these activities more often than every 8 hours, especially to help clear mucus.

D. Limiting fluid intake to 1,000 ml daily is incorrect. Adequate hydration is essential in COPD clients to help thin secretions and promote easier expectoration. A restriction on fluids could lead to thickened mucus and worsened respiratory status.

A. The AP points the probe posteriorly. B. The AP pulls the pinna up and back. C. The AP positions the client facing her. D. The AP inserts the probe with a straight, forward motion.

Correct Answer is B

Explanation

A. The AP points the probe posteriorly is incorrect. When using a tympanic thermometer for adults or children older than 3 years, the probe should be directed posteriorly and slightly upwards to align with the ear canal. The posterior direction is correct for adults, but this phrasing is not precise enough for the intended technique.

B. The AP pulls the pinna up and back is correct. When taking the temperature of a client older than 3 years using a tympanic thermometer, the pinna (ear) should be pulled up and back to straighten the ear canal and ensure accurate measurement. This action indicates the AP understands proper technique.

C. The AP positions the client facing her is incorrect. The client’s position does not directly affect the ability to take a tympanic temperature. The focus should be on positioning the ear and probe, not on facing the nurse.

D. The AP inserts the probe with a straight, forward motion is incorrect. The correct motion is straight into the ear canal, not forward, and it is more precise when the probe is inserted gently without forcing it.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is B

Explanation

A nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first?

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?

A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?