An older 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?
Remind the UAP to apply a fitted respirator mask before entering the client's room.
Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Assign the UAP to provide care for another client and assume full care of the client.
Review the need for the UAP to wear a face mask while in close contact with the client.
The Correct Answer is D
Given the older client's history of heart failure and current diagnosis of influenza, it is important for the nurse to ensure that appropriate infection control measures are being followed while providing care. In this scenario, the nurse observes the UAP wearing a gown and gloves to assist the client with sitting up to eat lunch. The nurse should review the need for the UAP to wear a face mask while in close contact with the client. Influenza is spread through respiratory droplets, so wearing a face mask is an important infection control measure to prevent the spread of the virus.
Reminding the UAP to apply a fitted respirator mask before entering the client's room may not be necessary in this situation, as a regular face mask may be sufficient for preventing the spread of influenza.
Additionally, the nurse should instruct the UAP to notify the nurse of any changes in the client's respiratory status. This will allow the nurse to monitor the client's condition closely and intervene promptly if needed.
Assigning the UAP to provide care for another client and assuming full care of the client may not be necessary, as long as appropriate infection control measures are being followed.
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Correct Answer is D
Explanation
A. Nonreactive pupils are not typically associated with pseudoparkinsonism.
B. Smacking lips is not typically associated with pseudoparkinsonism.
C. Serpentine limb movement is not typically associated with pseudoparkinsonism.
D. Correct. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol. It is characterized by motor symptoms similar to Parkinson's disease, including a shuffling gait, rigidity, bradykinesia (slowed movement), and resting tremor.
Correct Answer is D
Explanation
A. Incorrect. Open discussion is important to address the changes and challenges resulting from the stroke. Avoiding discussions might hinder effective communication and problem-solving.
B. Incorrect. Socialization with extended relatives can provide valuable support during this transition and should not be decreased without reason.
C. Incorrect. Authoritative communication might not be suitable for all family dynamics.
Effective communication should be respectful and tailored to the specific needs and preferences of the individuals involved.
D. Correct. Implementing firm but flexible boundaries allows for a healthy balance between support and maintaining the client's independence and autonomy.
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