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 A

Explanation

A. It's normal for the reservoir bag not to deflate completely during inspiration. A respiratory rate of 14 breaths/minute is within the normal range (12-20 breaths/minute). If the client is comfortable and their oxygen saturation is within the normal range, there is no need for intervention. Documenting the assessment data for future reference is sufficient.
B. Increasing the liter flow of oxygen may not be necessary if the client's oxygen saturation is within the normal range. It could also lead to oxygen toxicity if the flow is set too high.
C. Encouraging deep breaths may not be necessary if the client's respiratory rate is within the normal range.
D. Removing the mask to deflate the bag is not necessary and could interfere with the delivery of oxygen.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Listen to the ethics committee discussions and then inform the client what actions should be taken. C. Challenge members of the healthcare team whose opinions differ from the wishes of the client. D. Educate the client about current nursing literature findings related to the client's ethical dilemma.

Correct Answer is A

Explanation

A. Developing self-awareness of personal values is crucial for a nurse acting as an advocate. It ensures
that the nurse’s own beliefs and biases do not interfere with representing the client's wishes and values. This self-awareness helps the nurse advocate effectively for the client’s preferences and decisions without imposing their own personal values.
B. While listening to the ethics committee discussions is important for understanding the context of the ethical dilemma, informing the client about what actions should be taken might not align with the nurse’s role as an advocate. The nurse's role is to represent the client's wishes and interests, not to dictate actions based on the committee’s deliberations.
C. It is important to ensure the client’s wishes are represented, but challenging team members should be done respectfully and constructively. The nurse should focus on presenting the client’s viewpoint clearly and facilitating a discussion that considers the client’s preferences.
D. Educating the client about current literature can be helpful, but it is not the primary responsibility of the nurse in the role of an advocate at an ethics committee meeting. The nurse’s primary role is to
represent the client’s wishes and ensure their voice is heard in the ethical decision-making process.

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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 assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]