The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

Imbalanced nutrition: less than body requirements.

Impaired physical mobility.

Relocation stress syndrome.

Body image disturbance.

Answer and Explanation

The Correct Answer is A

A.   After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B.   While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C.   Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D.   Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.

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Correct Answer is B

Explanation

A. While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B. Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C. Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D. Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

A. Encourage the UAP to continue to assist the client down the hallway. B. Demonstrate to the UAP how to assist the client with ambulation more safely. C. Instruct the UAP to guide the client back to his room right away. D. Advise the UAP to stay nearby but allow the client to ambulate independently.

Correct Answer is B

Explanation

A. While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B. Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C. This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D. Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

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The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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