A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

A. Nursing care plan B. Controlled substance inventory record C. Incident report D. Provider's progress notes

Correct Answer is C

Explanation

A. Documenting in the nursing care plan is incorrect. The nursing care plan outlines interventions and client needs, but it is not used for documenting medication errors.

B. Recording in the controlled substance inventory record is incorrect. While the administration of a controlled substance must be recorded, the inventory record tracks medication usage and does not serve as documentation for errors.

C. Completing an incident report is correct. An incident report is used to document medication errors, allowing for review and quality improvement measures to prevent future occurrences.

D. Writing in the provider's progress notes is incorrect. The provider's progress notes focus on client status and treatment plans, not internal error reporting. However, the nurse should notify the provider about the error.

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is C

Explanation

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