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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 ["A","B"]

Explanation

Silence can be a natural part of the group therapy process, and individuals may need additional time to process their thoughts and feelings before contributing. By allowing the client extra time, the nurse creates a non-threatening space for the client to participate when they are ready.

In some group settings, certain members might dominate the conversation, making it challenging for others to contribute. By requesting that other group members be mindful of their speaking time, the nurse helps create space for the silent client to share their thoughts and experiences.

The nurse can privately communicate with the silent client outside the group session to offer support and explore any concerns or barriers they may be experiencing. This individualized attention can help the client feel valued and encourage their participation in future sessions. Appointing the client to lead the discussion or telling them to leave the group if they cannot contribute are not appropriate actions. These approaches can increase the client's discomfort and create a negative atmosphere, which goes against the principles of group therapy. It is important to foster an inclusive and supportive environment that encourages participation at each person's pace.

A. Colostrum provides many important antibodies that the newborn lacks. B. Colostrum contains iron, which is important for a newborn's brain development. C. Colostrum provides vitamin K. which is an essential nutrient for newborns. D. Colostrum contains a natural diuretic that stimulates the newborn to void.

Correct Answer is A

Explanation

Colostrum provides many important antibodies that the newborn lacks.

Colostrum is the thick, yellowish fluid produced by the breasts during the early days after giving birth. It is rich in antibodies, immune factors, and other beneficial components that provide important protection and support for the newborn's health. Colostrum is often referred to as "liquid gold" due to its valuable properties. Antibodies present in colostrum help to strengthen the newborn's immune system and provide protection against various infections and diseases.

These antibodies are especially important during the first few days of life when the newborn's own immune system is still developing.

Option B is incorrect because colostrum does not contain a significant amount of iron. Iron is generally obtained from other sources, such as breast milk or iron-fortified formula, to support the newborn's brain development.

Option C is incorrect because although colostrum contains various essential nutrients, it does not provide a significant amount of vitamin K. Vitamin K is typically given to newborns as a separate supplement to prevent vitamin K deficiency bleeding.

Option D is incorrect because colostrum does not act as a diuretic. Its primary role is to provide the newborn with essential nutrients, antibodies, and immune factors to support their overall health and development.

In summary, colostrum is important for the newborn because it provides valuable antibodies that the newborn lacks, helping to strengthen their immune system and protect against infections and diseases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?

Correct Answer is ["A","B"]

Explanation

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby? Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

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?