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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 A

Explanation

Choice A- Ask the family if they want to participate in postmortem care Asking the family if they want to participate in post-mortem care is an important step to involve them in the process and respect their wishes. Some families may prefer to have healthcare professionals handle the post-mortem care, while others may want to participate in certain aspects. It is crucial to communicate and collaborate with the family to ensure their preferences are respected. Choice B- Lie the head of the client's bed flat. This response is not appropriate. Elevate the head of the bed as soon as possible after death to prevent discoloration of the face. Choice C- Place medical equipment to the side of the client's bed. Is not directly related to the preparation for a post-mortem family viewing. However, it is important to ensure a respectful and organized environment during the viewing, so any unnecessary medical equipment or supplies should be removed from the immediate vicinity of the client's bed. Choice D-Remove the client's dentures to close their mouth. Leave dentures in the mouth to maintain facial shape.The mouth can be gently closed without removing dentures, unless there are specific cultural or family preferences regarding the dentures.

A. Provide a stimulating environment for the client. B. Use confrontation to manage the client's behavior. C. Limit the number of choices for the client. D. Use written signs to assist the client with locating the bathroom.

Correct Answer is ["A","C","D"]

Explanation

Correct answers: A, C, D

A. Provide a stimulating environment for the client. A structured and stimulating environment can help maintain cognitive function and reduce restlessness or agitation. Activities such as music therapy, puzzles, or light exercise can be beneficial.

C. Limit the number of choices for the client. Too many choices can be overwhelming for a client with Alzheimer's disease, leading to frustration and anxiety. Providing limited and simple choices helps them feel more in control without confusion.

D. Use written signs to assist the client with locating the bathroom. Clients with Alzheimer's may have difficulty recognizing familiar places. Labeling key areas, such as the bathroom or bedroom, with clear written signs or pictures can help them navigate their environment independently.

Incorrect:

B. Use confrontation to manage the client's behavior. Confrontation can lead to increased agitation, anxiety, or aggression in clients with Alzheimer's. Instead, caregivers should use redirection, reassurance, and validation therapy to manage behaviors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

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 collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?