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 B
Explanation
Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.
It also allows the nurse to correct any misunderstandings and reinforce key points.
Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.
Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.
Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.
Correct Answer is B
Explanation
Limiting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and increase the risk of infection. Older adults should drink about 2 liters of fluid per day unless they have a medical condition that requires fluid restriction.
Choice A is correct because taking diuretics in the morning can reduce nocturia and improve sleep quality.
Choice C is correct because using a commode next to the bed can prevent falls and injuries that may occur when trying to reach the bathroom in a hurry.
Choice D is correct because using a commode in the room can preserve dignity and comfort, and reduce skin breakdown and odor that may result from wearing adult briefs.
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