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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.

Answer and Explanation

Correct Answer : A,B,C,D,E,G

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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Correct Answer is ["C"]

Explanation

A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.

C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

A. Write the information at an 8th-grade reading level. B. Explain medical terminology using basic, one-syllable words. C. Use a 12-point font size. D. Present information from complex to simple.

Correct Answer is A

Explanation

Explanation

A. Write the information at an 8 th grade reading level

Writing the information at an 8th-grade reading level ensures that it is accessible and understandable to a wide range of individuals in the community. Hypertension is a common health condition, and it is important to provide information in a clear and concise manner that can be easily comprehended by the target audience.

Explaining medical terminology using basic, one-syllable in words in (option B) is not recommendable because it may oversimplify the information and potentially undermine the importance of accuracy and precision in healthcare communication.

Using a 12-point font size in (option C) is not recommendable because it is a general guideline for readability, but it is not the most critical aspect when developing a brochure. The readability of the content itself is more important than the specific font size.

D. Presenting information from complex to simple in (option D) is not recommendable because it is not the most effective approach when developing a brochure about hypertension. It is more beneficial to present information in a simple and straightforward manner from the beginning to enhance understanding and engagement.

Therefore, the nurse should write the information at an 8th-grade reading level (option A) to ensure that it is easily accessible and comprehensible for the target audience.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is ["C"]

Explanation

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

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 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 indicate the need for further evaluation?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?