An older adult client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

Review the need for the UAP to wear a face mask while in close contact with the client.

Remind the UAP to apply a fitted respirator mask before entering the client's room.

Assign the UAP to provide care for another client and assume full care of the client.

Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Answer and Explanation

The Correct Answer is A

A. Review the need for the UAP to wear a face mask while in close contact with the client: Influenza is transmitted through respiratory droplets, so the UAP should wear a mask in addition to gown and gloves when assisting the client.

B. Remind the UAP to apply a fitted respirator mask before entering the client's room:
A fitted respirator mask (e.g., N95) is generally used for airborne precautions such as tuberculosis which requires droplet precautions. A face mask is sufficient in this case.

C. Assign the UAP to provide care for another client and assume full care of the client:
While it may be necessary to adjust staffing, this is an extreme response. The UAP can continue caring for the client with proper precautions.

D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status:
While it is always important for the UAP to report changes in the client’s condition, this action does not address the immediate concern about PPE use.

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Correct Answer is C

Explanation

A. Iron-rich meats: While iron is essential for preventing anemia, it does not contribute significantly to bone mineral density. These foods are not a primary recommendation for osteoporosis prevention, which focuses on calcium and vitamin D intake.

B. Water and herbal teas: Adequate hydration is important for overall health, but water and herbal teas do not contain the calcium or vitamin D needed to support bone health. They have minimal direct impact on preventing osteoporosis.

C. Low fat dairy products: Low fat dairy products like milk, yogurt, and cheese are rich in calcium and often fortified with vitamin D—both critical nutrients for maintaining bone density and preventing osteoporosis.

D. Fresh fruits and vegetables: Fruits and vegetables provide general nutritional support, but are not the most concentrated sources of bone-building nutrients like calcium. They support health broadly but are not the key dietary focus for osteoporosis.

A. Perform active range of motion exercises. B. Apply compression stockings. C. Give antispasmodic medications. D. Massage the extremities twice a week.

Correct Answer is C

Explanation

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

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An older adult client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is C

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A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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