A nurse assesses a patient with restraints. The nurse should:

Loosen the restraints and assess the patient’s skin.

Document the findings in the patient’s chart.

Continue to monitor the patient without making any changes.

Apply ice packs to reduce swelling.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

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Correct Answer is B

Explanation

Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.

Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.

A. Speak loudly and use hand gestures. B. Stand with the light behind you. C. Use short, simple sentences. D. Avoid the use of written communication.

Correct Answer is C

Explanation

Choice A rationale
Speaking loudly can be counterproductive as it may distort the sound and make it harder for the client to understand. Using hand gestures can be helpful, but it should be combined with clear, simple sentences.
Choice B rationale
Standing with the light behind you can create shadows on your face, making it difficult for the client to read your lips. It is better to face the client directly with good lighting on your face.
Choice C rationale
Using short, simple sentences is effective for communicating with clients who are hard of hearing. It helps ensure that the client can understand the information being conveyed.
Choice D rationale
Avoiding the use of written communication is not advisable. Written communication can be a helpful tool for clients who are hard of hearing, as it provides a visual aid to support verbal communication.

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A nurse assesses a patient with restraints. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In what patient situations would a partial ongoing assessment be best performed?

Correct Answer is B

Explanation

A nurse is caring for a client who is hard of hearing. What action should the nurse take?

Correct Answer is C

Explanation

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