An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

Use background music to promote relaxation.

Turn on overhead lights while giving instructions.

Stand behind the client to avoid intimidation.

Provide handouts written at a 12th grade reading level.

Answer and Explanation

The Correct Answer is D

A. Background music may be distracting rather than helpful during teaching.

B.   Adequate lighting is crucial for older adults to clearly see and read instructional materials. However, overhead lights may be distracting and disorienting for an older adult.
C.   Standing behind the client might actually increase feelings of intimidation or discomfort. It's better to face the client to facilitate communication.
D.   Providing handouts written at a 12th grade reading level ensures that the information is accessible and understandable for the majority of adults.

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Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

A. Right foot pale with sluggish capillary refill. B. Circumferential edema of right foot. C. Reports throbbing right leg pain. D. Increased temperature to lower extremity.

Correct Answer is A

Explanation

A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.

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An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?