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As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client with dementia. Which component is the priority to determine from their family?
- A. BMI
- B. Usual times for meals/snacks
- C. Favorite foods
- D. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Any difficulty swallowing. This is the priority component to determine because clients with dementia are at higher risk for dysphagia, which can lead to aspiration pneumonia and malnutrition. Identifying swallowing difficulties early can help prevent complications.
A: BMI is important but not the priority in this case.
B: Usual times for meals/snacks may be important but not as critical as identifying swallowing issues.
C: Favorite foods can provide insight into preferences but do not address immediate health risks.
In summary, identifying any difficulty swallowing is crucial for the safety and well-being of the client with dementia.
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Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station?
- A. 43 yo client post-op following laparoscopic cholecystectomy
- B. 61 yo client being admitted for telemetry to rule out MI
- C. 50 yo client post-op following open reduction internal fixation of ankle
- D. 79 yo client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.
A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. "client evaluates his behavior after social interaction"
- B. client states he is learning to trust others
- C. client wishes to find meaningful relationships
- D. client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D because expressing concerns about the next generation aligns with Erikson's task of generativity vs. stagnation during middle adulthood. This stage involves contributing to the well-being of future generations. Choice A focuses on self-reflection, not generativity. Choice B refers to Erikson's trust vs. mistrust stage in infancy. Choice C relates to forming intimate relationships in young adulthood. This highlights the importance of understanding Erikson's psychosocial stages to identify appropriate behaviors.
Nurse is caring for a client with SARS. The nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate the rationale for reporting? (Select all that apply.)
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A,B,C,E
Rationale: The correct answers are A, B, C, and E. Reporting communicable diseases helps in planning and evaluating control strategies by identifying trends and risk factors. It also aids in determining public health priorities by allocating resources effectively. Reporting ensures proper medical treatment for infected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Incorrect choices: D - Reporting does not specifically identify endemic diseases; F & G - Choices are not provided.
Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.