Admission Assessment Day 1, 1000:
An older adult client was transferred to the ICU after they developed 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: 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.
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 C
Explanation
"I should decrease my salt intake to 2 grams per day." - This statement is correct. Decreasing salt intake is an important dietary modification for individuals with hypertension. The general recommendation is to limit sodium intake to 2 grams per day or less. Reducing salt intake can help lower blood pressure levels.
"I can have two glasses of wine with dinner." - This statement is not accurate. While moderate alcohol consumption may have some health benefits, it is generally recommended to limit alcohol intake, especially for individuals with hypertension. The specific recommendation for alcohol consumption may vary depending on individual factors and should be discussed with a healthcare provider.
"I should exercise for 15 minutes two times per week." - This statement is not accurate. While any amount of physical activity is beneficial, the current recommendations for adults include at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities on two or more days. The client should aim for a higher frequency and duration of exercise to achieve optimal health benefits.
Correct Answer is C
Explanation
When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:
- Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
- Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
- Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
- Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
- Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.
Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.
The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.
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