A home health nurse is caring for a group of older adult clients. Which of the following statements by a client is an indication they may be experiencing social isolation?

"I am not able to walk for very long so I ride the stationary exercise bike at the gym."

"I enjoy having lunch with my grandchildren every other Sunday."

"I have a few friends over for coffee a couple of times a week."

"I have a lot of arthritis pain, so I only leave my house to get the mail."

Answer and Explanation

The Correct Answer is D

A.   Although this client may have physical limitations, they are still engaging in social activities by going to the gym, indicating less likelihood of social isolation.
B.   This client has regular social interactions with family members, suggesting they are not socially isolated.
C.   Regular social gatherings with friends indicate social engagement and are not indicative of social isolation.
D.   Restricting activities outside the home to only essential tasks like getting the mail due to pain or other reasons can indicate social isolation and limited social interactions.

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Correct Answer is C

Explanation

A. Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.

B. Sputum specimens should be collected in a sterile container to prevent contamination.
C. Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D. Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.

A. "Use povidone-iodine to clean around the stoma." B. "Cut the opening of the pouch / of an inch larger than the stoma." C. "Empty the ostomy pouch when it becomes one-third full of contents." D. "Place a piece of gauze over the stoma while changing the pouch." E. "Expect the stoma to turn a purple-blue color as it heals."

Correct Answer is ["B","C","D"]

Explanation

A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.

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A home health nurse is caring for a group of older adult clients. Which of the following statements by a client is an indication they may be experiencing social isolation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?

A nurse is caring for a client who has recently retired from their job. The client states they feel like they no longer have a purpose. Which of the following responses should the nurse make?

A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)

A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?