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 B
Explanation
B. Herpes simplex is a viral infection that causes skin eruptions or lesions. To promote healing and prevent secondary infections, it is important to keep the affected area clean. Cleansing the skin eruptions with povidone-iodine, an antiseptic solution, can help reduce the risk of infection and promote healing.
The other options are incorrect:
A. Over-the-counter topical ointments are generally not recommended for the treatment of herpes simplex outbreaks. It is best to consult with a healthcare provider for appropriate medication and treatment options.
C.Herpes simplex is a viral infection, and antibiotics are used to treat bacterial infections. Antibiotics are not effective against viral infections like herpes simplex.
D. Placing disposable thermometers in the client's room is not directly related to the management of a herpes simplex outbreak. It is important to focus on interventions specific to the client's condition.
Correct Answer is B
Explanation
Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.
The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.
The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.
Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.
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