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.
Correct Answer : A,B,C,D,E,G
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- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.
Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.
Correct Answer is D
Explanation
Hair loss is a common side effect of chemotherapy, and it can have a significant impact on the client's self-esteem and body image. The nurse should respond with empathy and provide supportive information and resources to help the client cope with hair loss.
Offering head-covering options such as wigs, scarves, or hats can help the client feel more comfortable and confident during the hair loss process.
The other responses are less appropriate:
A. "I can't imagine how difficult it would be to lose my hair." While expressing empathy is important, it is crucial to focus on the client's needs and experiences rather than the nurse's own feelings. This response may unintentionally minimize the client's concerns.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing or minimizing the client's concerns about hair loss can be invalidating and may not address the emotional impact it can have on the client. It is important to provide information and support regarding hair loss management as part of comprehensive care.
C. "Let's discuss this when we have more time." This response delays addressing the client's concerns and may leave the client feeling unheard or dismissed. The nurse should make an effort to provide support and information in a timely manner to address the client's needs.
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