Admission Assessment Day 1, 1000:
An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.
Past Medical History: hypertension, congestive heart failure, Parkinson's disease
Allergies: penicillin (anaphylaxis)
Social History: Client has visual loss but didn't bring their glasses. The client is hard of hearing.
Hearing aids in place.
Which of the following actions should the nurse take? Select all that apply.
Request that the client's family bring the client's eyeglasses from home.
Reorient the client often.
Acknowledge the client's feelings.
Provide the client with information about what to expect during their care.
Write the full date on the client's whiteboard.
Ask the client's partner to stay with the client as much as possible.
Maintain a well-lit environment.
Request that the client have the same caregivers with every shift.
Correct Answer : A,B,C,D,E,G
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- Request that the client's family bring the client's eyeglasses from home: This is important to ensure that the client has optimal vision and can see clearly, considering their visual loss. Having their eyeglasses will improve their ability to communicate and understand their surroundings.
- Reorient the client often: Reorientation is important for clients who may be disoriented due to their medical condition or unfamiliar environment. Regularly reminding the client of their location, date, and situation can help them maintain orientation.
- Acknowledge the client's feelings: Acknowledging and validating the client's feelings can help establish rapport and promote a therapeutic relationship. It shows empathy and understanding, which can contribute to the client's overall well-being.
- Provide the client with information about what to expect during their care: Providing information to the client about their care helps promote autonomy and active participation in their own healthcare. It can reduce anxiety and improve the client's overall experience.
- Write the full date on the client's whiteboard: Clearly documenting the full date on the client's whiteboard helps the client stay oriented to the current date and time.
- Maintain a well-lit environment: Ensuring a well-lit environment is important, especially for clients with visual impairment. Sufficient lighting can enhance the client's ability to see and navigate their surroundings.
It's worth noting that while asking the client's partner to stay with the client as much as possible may be beneficial, it may not always be feasible or within the nurse's control. Additionally, requesting the client to have the same caregivers with every shift may not be possible due to staffing constraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A, Nervousness
Levothyroxine is a medication used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones. Thyrotoxicosis, on the other hand, is a condition characterized by an excess of thyroid hormones in the body, which can occur as a side effect of levothyroxine or other thyroid medications.
Nervousness is a common symptom of thyrotoxicosis. Excess thyroid hormones can lead to increased sympathetic nervous system activity, causing symptoms like nervousness, restlessness, anxiety, and palpitations.
Pruritus (itching) in (option B) is not correct because it is not a typical manifestation of thyrotoxicosis. Itching is not directly related to thyroid hormone levels and is more likely to be associated with other conditions or medication side effects.
Cough In (option C) is not correct because it is not a typical manifestation of thyrotoxicosis. Coughing is not a symptom directly related to thyroid hormone levels and is more likely to be associated with respiratory or other conditions.
Polyuria (increased urination) in (option D) is not correct because it is not a typical manifestation of thyrotoxicosis. Polyuria is not a symptom directly related to thyroid hormone levels and is more likely to be associated with other conditions, such as diabetes or kidney problems.
If the client experiences symptoms of thyrotoxicosis, such as nervousness, palpitations, or any other concerning signs, it is essential to notify the healthcare provider promptly. The provider may need to adjust the dosage of levothyroxine or consider other treatment options to address the excess thyroid hormone levels and ensure the client's well-been
Correct Answer is B
Explanation
The nurse should describe hyperactive bowel sounds as sounds that are loud, high-pitched, and increased in frequency and intensity. They are more frequent than the normal bowel sounds, with a rapid succession of sounds occurring at a rate greater than 5 to 30 sounds per minute.
Hyperactive bowel sounds can be heard in conditions such as gastroenteritis, diarrhea, and early mechanical bowel obstruction. They indicate increased bowel motility and are often associated with increased peristalsis.
To differentiate hyperactive bowel sounds from normal or hypoactive bowel sounds, the nurse can explain that hypoactive bowel sounds are decreased or absent sounds that occur when the bowel motility is decreased, such as in conditions like paralytic ileus or after abdominal surgery. Normal bowel sounds are typically soft, low-pitched, and occur at a rate of 5 to 30 sounds per minute.
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