A nurse is admitting an older adult from Mumbai, India who is visiting family members in the US. Which of the following would be most appropriate for the nurse to say?

"Your roommate is Catholic and her priest comes to see her, is that a problem for you?"

"Can I call the Hindu hospital chaplain to make a visit with you today?"

"Can you tell me how your culture will impact the care I will give?"

“I will be sure to get a menu for you without any beef and beef related foods."

Answer and Explanation

The Correct Answer is C

A. "Your roommate is Catholic and her priest comes to see her, is that a problem for you?": This statement may inadvertently introduce a concern or discomfort about the roommate's religious practices. It does not focus on the needs or preferences of the patient and could be perceived as dismissive of the patient's own beliefs.

B. "Can I call the Hindu hospital chaplain to make a visit with you today?": While offering spiritual support is important, this question assumes the patient identifies with Hinduism without confirming their preferences or beliefs first. It is better to first ask about the patient’s specific cultural or spiritual needs.

C. "Can you tell me how your culture will impact the care I will give?": This approach demonstrates respect for the patient's cultural background and invites them to share their beliefs, values, and preferences. It allows for an open dialogue and helps the nurse understand how to provide culturally competent care tailored to the patient’s needs.

D. "I will be sure to get a menu for you without any beef and beef-related foods.": While it is important to accommodate dietary restrictions, this statement assumes the patient avoids beef without first confirming their dietary preferences or cultural practices. It is essential to ask about dietary restrictions directly to ensure the patient’s preferences are respected.

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Correct Answer is A

Explanation

A. The client faces the direction of movement when sliding an object across the floor: This finding indicates that the client is using proper body mechanics. Facing the direction of movement helps maintain balance and reduces the risk of injury when sliding or moving objects.

B. When moving an object to one side, the client puts his weight on his heels: Putting weight on the heels can lead to a loss of balance and stability. Proper body mechanics involve distributing weight evenly and maintaining a stable base, which is not reflected in this finding.

C. When pushing an object, the client moves his front foot backward: This action is not a proper body mechanic. When pushing, the client should maintain a stable stance with feet positioned appropriately to provide support and leverage. Moving the front foot backward may compromise stability.

D. The client stands with his feet close together when lifting an object: Standing with feet close together can decrease stability and increase the risk of falls. Proper body mechanics recommend a wider stance for better support and balance when lifting or moving objects.

A. Obtain the provider's prescription renewal every 72 hr. B. Document restraint checks and client status every 2 hr. C. Implement passive range-of-motion exercises. D. Educate the client's family about restraint use. E. Release the restraint and reposition the client every 4 hr.

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

Explanation

A. Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Restraints must be prescribed by a provider and typically require renewal every 24 to 72 hours, depending on hospital policy and the client's needs. Continuous monitoring and justification for the use of restraints are necessary for ethical and legal compliance.

B. Document restraint checks and client status every 2 hr.: Regular documentation of restraint checks and the client’s status is vital for ensuring safety and monitoring for any potential complications, such as skin breakdown or circulatory issues. Frequent checks help ensure that restraints are being used appropriately and that the client’s needs are being met.

C. Implement passive range-of-motion exercises: Incorporating passive range-of-motion exercises is important for preventing joint stiffness, muscle atrophy, and promoting circulation in an immobile client. These exercises can help maintain some level of mobility and prevent complications associated with prolonged immobility.

D. Educate the client's family about restraint use: Providing education to the family about the rationale for using restraints, their purpose, and the monitoring process is essential for transparency and support. This helps the family understand the situation and the measures being taken to ensure the client’s safety.

E. Release the restraint and reposition the client every 4 hr.: This intervention is not sufficient, as restraints should typically be released more frequently, generally every 1 to 2 hours, to assess the client's condition, provide comfort, and allow for repositioning. Releasing restraints every 4 hours may increase the risk of complications and does not align with best practices for care.

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A nurse is admitting an older adult from Mumbai, India who is visiting family members in the US. Which of the following would be most appropriate for the nurse to say?

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