An 86-year-old resident in an extended care facility will not leave her room until her hair is combed, her lipstick is on, and she is well groomed.
The resident is sociable and completely independent, but it is lunchtime before she is ready to leave her room.
Which plan should a nurse make regarding breakfast for this client?
Omit her breakfast.
Serve her breakfast in her room.
Get her up early enough to be ready for breakfast.
Have her go to breakfast regardless of the state of her grooming.
The Correct Answer is B
This is because the resident is independent and sociable, and has the right to choose her own grooming preferences.
Serving her breakfast in her room will respect her autonomy and dignity, and prevent her from missing a meal.
Choice A is wrong because omitting her breakfast will deprive her of nutrition and hydration, and may cause health problems.
It will also violate her rights as a resident.
Choice C is wrong because getting her up early enough to be ready for breakfast will disrupt her sleep cycle and may cause fatigue or stress.
It will also impose the nurse’s values on the resident, and disregard her preferences.
Choice D is wrong because having her go to breakfast regardless of the state of her grooming will embarrass her and lower her self-esteem.
It will also disrespect her culture and values, and may affect her social interactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A heart murmur is a priority assessment for a toddler who is diagnosed with fetal alcohol syndrome because it may indicate a congenital heart defect, which can affect the child’s growth, development and oxygenation. According to the health search results, fetal alcohol syndrome can cause heart and kidney problems, among other complications.
Choice A is wrong because small head size is a common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has microcephaly, which is associated with intellectual and learning disabilities.
Choice B is wrong because poor coordination is another common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has problems with motor skills and balance.
Choice C is wrong because speech and language delays are also common features of fetal alcohol syndrome, but they are not a priority assessment. They indicate that the child has problems with communication and social skills.
Correct Answer is B
Explanation
“Tell me what your pain feels like.” This question allows the nurse to assess the quality of pain, which is one of the characteristics of pain that can help determine its cause and treatment. Quality of pain refers to how the client describes the pain, such as sharp, dull, burning, throbbing, etc.
Choice A is wrong because it assesses the intensity of pain, not the quality. Intensity of pain is how much the pain hurts on a scale of 0 to 10 or using other methods.
Choice C is wrong because it assesses the precipitating factors of pain, not the quality. Precipitating factors are events or activities that trigger or worsen the pain.
Choice D is wrong because it assumes a specific quality of pain without asking the client. The nurse should not suggest words to describe the pain, but rather let the client use their own words.
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