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Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed a fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease Allergies: penicillin (anaphylaxis)

Social History: The client has visual loss but didn't bring their glasses. The client is hard of hearing. Hearing aids in place.

Which of the following actions should the nurse take? Select all that apply.

Request that the client's family bring the client's eyeglasses from home.

Reorient the client often.

Acknowledge the client's feelings.

Provide the client with information about what to expect during their care.

Write the full date on the client's whiteboard.

Ask the client's partner to stay with the client as much as possible.

Maintain a well-lit environment.

Request that the client have the same caregivers with every shift.

Answer and Explanation

Correct Answer : A,B,C,D,E,G

1. 1. Request that the client's family bring the client's eyeglasses from home: This is important to ensure that the client has optimal vision and can see clearly, considering their visual loss. Having their eyeglasses will improve their ability to communicate and understand their surroundings.
  2. Reorient the client often: Reorientation is important for clients who may be disoriented due to their medical condition or unfamiliar environment. Regularly reminding the client of their location, date, and situation can help them maintain orientation.
  3. Acknowledge the client's feelings: Acknowledging and validating the client's feelings can help establish rapport and promote a therapeutic relationship. It shows empathy and understanding, which can contribute to the client's overall well-being.
  4. Provide the client with information about what to expect during their care: Providing information to the client about their care helps promote autonomy and active participation in their own healthcare. It can reduce anxiety and improve the client's overall experience.
  5. Write the full date on the client's whiteboard: Clearly documenting the full date on the client's whiteboard helps the client stay oriented to the current date and time.
  6. Maintain a well-lit environment: Ensuring a well-lit environment is important, especially for clients with visual impairment. Sufficient lighting can enhance the client's ability to see and navigate their surroundings.

It's worth noting that while asking the client's partner to stay with the client as much as possible may be beneficial, it may not always be feasible or within the nurse's control. Additionally, requesting the client to have the same caregivers with every shift may not be possible due to staffing constraints.

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Correct Answer is D

Explanation

It is common for school-age children to exhibit magical thinking and believe that their actions or thoughts have the power to cause events, including the illness or death of a loved one.

Therefore, it would be expected for the school-age brother of a child with terminal cancer to have thoughts or beliefs that his own behavior is causing his brother's death. It is important for the nurse to provide age-appropriate education and support to help the brother understand the nature of the illness and address any misconceptions or feelings of guilt.

A. Wears a face mask around others B. Increased intake of green, leafy vegetables C. Uses a firm-bristled toothbrush D. Sleeps 8 to 10 hr per night

Correct Answer is C

Explanation

Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired blood clotting and an increased risk of bleeding. The use of a firm-bristled toothbrush can cause trauma to the gums and oral tissues, increasing the risk of bleeding in someone with thrombocytopenia. It is recommended for individuals with thrombocytopenia to use a soft-bristled toothbrush to minimize the risk of oral bleeding.

Wearing a face mask around others, increased intake of green, leafy vegetables, and getting an adequate amount of sleep does not directly increase the client's risk for injury in the context of thrombocytopenia. These practices are generally beneficial for overall health and well-being.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

Correct Answer is C

Explanation

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

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?

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?