The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

Imbalanced nutrition: less than body requirements.

Impaired physical mobility.

Relocation stress syndrome.

Body image disturbance.

Answer and Explanation

The Correct Answer is A

A.   After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B.   While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C.   Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D.   Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.

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Correct Answer is C

Explanation

A. This description is more characteristic of a Stage 3 or Stage 4 pressure injury. Stage 3 pressure injuries involve full-thickness skin loss and may expose subcutaneous tissue, and Stage 4 involves extensive damage with possible exposure of muscle, bone, or tendon. Sloughing (a type of necrotic tissue) is not typical of Stage 2 pressure injuries.
B. This description is more indicative of a Stage 1 pressure injury. Stage 1 injuries are characterized by non-blanchable erythema of intact skin, and pain or discomfort in the affected area is common. Stage 1 does not involve the loss of skin integrity, so it would not be the appearance of a Stage 2 injury.
C. This description accurately matches the appearance of a Stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red or pink wound bed. It does not extend through the entire thickness of the skin.
D. This description aligns with Stage 3 or Stage 4 pressure injuries, which involve full-thickness skin loss with possible necrotic tissue and deep pockets of infection. These stages involve significant tissue damage beyond what is seen in Stage 2 injuries.

A. Take an over-the-counter laxative every morning. B. Drink six to eight large glasses of water daily. C. Try using over-the-counter enemas when needed. D. Walk around the block or further every day.

Correct Answer is B

Explanation

A. While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B. Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C. Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D. Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is C

Explanation

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?