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 A

Explanation

A. Decreasing the time intervals between toileting can help prevent accidents by ensuring that the resident has more frequent opportunities to use the bathroom. Encouraging Kegel exercises (pelvic floor exercises) can help strengthen the muscles responsible for controlling urination and may improve incontinence.
B. Using disposable undergarments and changing them frequently can help manage incontinence and protect the skin from irritation and breakdown. However, this intervention primarily addresses the symptoms of incontinence rather than the underlying causes.
C. Limiting fluid intake in the evening can reduce the likelihood of nocturia (nighttime urination) and may help in managing urinary incontinence. However, reducing fluid intake can also lead to dehydration and other health issues.
D. Offering emotional support and reassurance is important for the resident’s mental well-being and can help reduce anxiety related to incontinence. Understanding that urinary incontinence is common among older adults can be comforting, but this approach alone does not address the practical management of the condition or contribute to improving urinary control.

A. Ask the colleague why the action is being performed. B. Remind the colleague of information security principles. C. Send email to facility administrators reporting the action. D. Comment about the action on a staff discussion board.

Correct Answer is B

Explanation

A. While this may provide some insight into the colleague's motivations, it doesn't directly address the issue of patient privacy and confidentiality.
B. Reminding the colleague of information security principles helps reinforce the importance of maintaining client confidentiality and proper handling of sensitive information. This action promotes awareness and correction of improper practices without escalating the situation unnecessarily.
C. Reporting the issue to the facility administrators may be necessary if the colleague continues to violate privacy and confidentiality principles. However, it's important to address the issue directly with the colleague first.
D. Publicly discussing the issue on a staff discussion board could be embarrassing for the colleague and may not be the most effective way to address the problem.

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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

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?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?