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 A
Explanation
Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.
Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.
Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.
Correct Answer is A
Explanation
A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.
C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.
D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
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