A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

"Client fell out of bed and cut his forehead due to sedative-induced confusion."

"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."

Answer and Explanation

The Correct Answer is C

A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."

This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.

B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.

C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.

D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."

This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.

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Correct Answer is B

Explanation

A. Palliative care focuses on providing comfort and relief from symptoms for individuals with serious illnesses, often those with life-limiting conditions. Respite care is not specifically designed for palliative care but can complement it by offering temporary relief to caregivers.

B. Respite care is a form of temporary care that allows caregivers a break or time off from their responsibilities. It is intended to provide short-term relief and support for family members or caregivers who are taking care of individuals with chronic illnesses, disabilities, or age-related conditions.

C. Restorative care involves interventions and services aimed at improving an individual's functional abilities and promoting independence. Respite care is not primarily focused on restorative care but rather on giving caregivers a temporary break.

D. Pain management is a specialized area of care that focuses on assessing and treating pain. Respite care, while it may involve managing symptoms during the temporary care period, is not specifically designed for pain management.

A. Improved speech patterns B. Decreased tremors C. Increased bladder function D. Diminished drooling

Correct Answer is B

Explanation

A. Improved speech patterns:

While selegiline may contribute to overall improvement in motor function and quality of life for individuals with Parkinson's disease, it is not specifically known for targeting speech patterns.

B. Decreased tremors:

This is the correct therapeutic outcome. Selegiline is a monoamine oxidase type B (MAO-B) inhibitor that helps increase dopamine levels in the brain. Reduction of tremors is a common therapeutic effect in Parkinson's disease.

C. Increased bladder function:

Selegiline primarily affects motor symptoms in Parkinson's disease and is not directly associated with changes in bladder function.

D. Diminished drooling:

While drooling can be a symptom of Parkinson's disease, selegiline's primary focus is on motor symptoms, and its impact on drooling may be variable. Other interventions may be considered for managing drooling in Parkinson's disease.

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Naxlex Comprehensive Predictor Exams

A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver asks about the purpose of a respite care program, the nurse should reply that it provides which of the following services?

Correct Answer is B

Explanation

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication?

Correct Answer is B

Explanation

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?