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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A.This statement reflects the client's emotional response to their condition, which is important to address, but it does not indicate a need for immediate medical intervention.

B.Psoriasis is a chronic skin condition characterized by the rapid buildup of skin cells, resulting in thick, red, scaly patches on the skin. Treatment for psoriasis often involves the use of topical medications that are applied to the affected areas. This is a good practice. Old medication should be removed before applying a new dose to ensure the effectiveness of the treatment.

C.This is a reasonable practice as some fabric softeners may contain ingredients that can irritate sensitive skin, including the skin affected by psoriasis. Avoiding fabric softeners or using hypoallergenic alternatives can help reduce potential irritation.

D.Sunlight exposure can actually be beneficial for clients with psoriasis, as ultraviolet (UV) light can help reduce the growth of skin cells and alleviate symptoms. If the client is limiting their sunlight exposure, they might be missing out on a potential therapeutic benefit. However, it is important to balance sun exposure and avoid overexposure to prevent skin damage.

A. Giving change-of-shift report to a nurse outside the client's room B. Discussing a client's prognosis with an assistive personnel who is caring for the client C. Writing a client's diagnosis on the message board in the client's room D. Discarding worksheets containing client information in a wastebasket

Correct Answer is A

Explanation

When providing a change-of-shift report, it is important to do so in a private and secure area away from public spaces. Sharing client information outside the client's room helps maintain confidentiality and prevents unauthorized individuals from overhearing sensitive information. Discussions about a client's prognosis should be limited to the appropriate healthcare professionals involved in the client's care. Sharing this information with an assistive personnel who is not directly involved in the client's care breaches confidentiality.

Displaying a client's diagnosis on a message board in a public area breaches confidentiality. It is essential to respect and protect a client's privacy by avoiding the unnecessary disclosure of sensitive information.

Proper disposal of documents containing client information is crucial to maintain confidentiality. Discarding worksheets with client information in a wastebasket without ensuring they are securely destroyed or shredded poses a risk of unauthorized access to sensitive information.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

Correct Answer is A

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse is reviewing the medical record of a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicates the need for further evaluation? Select all that apply.