An 86-year-old resident in an extended care facility will not leave her room until her hair is combed, her lipstick is on, and she is well groomed.

The resident is sociable and completely independent, but it is lunchtime before she is ready to leave her room.
Which plan should a nurse make regarding breakfast for this client?

Omit her breakfast.

Serve her breakfast in her room.

Get her up early enough to be ready for breakfast.

Have her go to breakfast regardless of the state of her grooming.

Answer and Explanation

The Correct Answer is B

This is because the resident is independent and sociable, and has the right to choose her own grooming preferences.

Serving her breakfast in her room will respect her autonomy and dignity, and prevent her from missing a meal.

Choice A is wrong because omitting her breakfast will deprive her of nutrition and hydration, and may cause health problems.

It will also violate her rights as a resident.

Choice C is wrong because getting her up early enough to be ready for breakfast will disrupt her sleep cycle and may cause fatigue or stress.

It will also impose the nurse’s values on the resident, and disregard her preferences.

Choice D is wrong because having her go to breakfast regardless of the state of her grooming will embarrass her and lower her self-esteem.

It will also disrespect her culture and values, and may affect her social interactions.

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Correct Answer is B

Explanation

“I apologize for not hearing you say that. Is there a better day for you?”.

This response shows empathy and respect for the client’s feelings and preferences.

It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.

It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.

It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.

Choice D is wrong because it is persuasive and manipulative.

It does not address the client’s concerns or explore other options.

The nurse-client relationship is based on trust, respect, and collaboration.

The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.

A. Formed stool two times per day, every day, for one week. B. Use of soap sud enemas weekly to promote elimination. C. Continued use of laxatives at half of the prescribed dose. D. A formed, soft stool at regular intervals without the use of a laxative.

Correct Answer is A

Explanation

Formed stool two times per day, every day, for one week. This indicates that bowel training is attaining the desired outcome because it shows regularity and consistency of bowel movements without the use of laxatives or enemas.

Choice B is wrong because soap sud enemas are not recommended for bowel training as they can irritate the bowel and cause fluid and electrolyte imbalance.

Choice C is wrong because continued use of laxatives can inhibit the natural defecation reflexes and cause dependency.

Choice D is wrong because a formed, soft stool at regular intervals without the use of a laxative is a normal defecation pattern, not an indication of fecal incontinence.

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Naxlex Comprehensive Predictor Exams

A client in the clinic states, “I already told you I can’t come back on Friday.” Which response by a nurse would be likely to repair the client-nurse relationship?

Correct Answer is B

Explanation

Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

Correct Answer is A

Explanation

Warfarin sodium (Coumadin) is ordered for a client. The client asks the nurse about dietary restrictions while taking this medication. Which of the following foods should be limited?

The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).

Which technique is most appropriate for a nurse to use when cleansing a pressure ulcer?

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Which abbreviation indicates a medication is to be administered after meals?

The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?

A client has been recently started on phenelzine, a monoamine oxidase inhibitor (MAOI) for depression. Which statement indicates that the client requires further educational reinforcement about the medication?

A health care provider prescribes one ounce of an elixir medication for a client. How many milliliters (mL) of medication should the nurse instruct the client to take during discharge teaching?