An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:

reflex tone

body for bruising

serum creatinine level

prothrombin time

Answer and Explanation

The Correct Answer is D

A.   Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B.   Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C.   While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D.   Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.

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Correct Answer is B

Explanation

A. controlling the interview by selecting the memories to be discussed: Guided reminiscence should be a collaborative process between the nurse and the patient. The nurse should facilitate the conversation and encourage the patient to share their own memories, rather than imposing specific topics.

B. Guided reminiscence is a therapeutic technique that involves helping individuals recall and reflect on past experiences. The goal is to promote positive emotions, improve cognitive function, and enhance a sense of well-being.
C. While it may be helpful to break up the reminiscence sessions into shorter intervals, the focus should be on creating a comfortable and supportive environment for the patient to share their memories.
D. While it may be helpful to prompt the patient to recall specific memories, the emphasis should be on allowing the patient to freely explore their own memories and experiences.

A. Patients mental status B. All pertinent nursing care C. Visitors the patient had during the shift D. Status of lung sounds E. The patients favorite TV shows

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

Explanation

A. The patient's mental status is crucial for understanding their current cognitive and emotional condition. This information helps the incoming nurse assess whether there have been any changes or concerns regarding the patient's orientation, mood, or cognitive function.
B. Documenting all pertinent nursing care provides a comprehensive overview of what has been done for the patient during the shift, including any treatments, medications administered, and changes in the patient's condition.
C. While knowing who visited the patient might be relevant in some contexts, it is generally not a core component of clinical shift reports unless the visitors' presence impacted patient care or the patient’s condition. This information is usually not necessary for the shift report unless it directly affects the
patient’s care or treatment, such as if a visitor brought important information or had a significant impact on the patient.

D. The status of lung sounds is a specific aspect of the patient's physical assessment and can indicate respiratory issues or improvements. This data is necessary if the patient has a respiratory condition or if there have been recent changes in their respiratory status. It helps the incoming nurse evaluate the effectiveness of treatments and ongoing respiratory care.
E. Information about the patient's favorite TV shows is not relevant to clinical care and does not impact
the patient’s health status or the nursing interventions required. This information is not necessary for
the shift report as it does not contribute to the patient’s medical or care needs.

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An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse most effectively implements guided reminiscence during a patient interview by

Correct Answer is B

Explanation

What data are necessary to compile an effective end-of-shift report? (Select all that apply.)

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

Explanation

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