During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Keep the client's television on with the volume low

Insert an indwelling urinary catheter to minimize interaction with the client.

Consult the provider regarding administering a mild sedative on a schedule.

Move the client to a room near the nurses' station

Answer and Explanation

The Correct Answer is D

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.

B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.

C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.

D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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Correct Answer is D

Explanation

A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.

B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.

C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.

D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.

A. Obesity B. Acromegaly C. Estrogen replacement therapy D. Sedentary lifestyle

Correct Answer is D

Explanation

A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.

B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.

C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.

D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.

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During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Correct Answer is D

Explanation

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