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Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss?
- A. "Do you eat alone or with someone?"
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A, C, D, E
Rationale: Correct Answer: A, C, D, E
Rationale:
A. "Do you eat alone or with someone?" - This question helps determine social eating habits and potential lack of appetite due to loneliness.
C. "Have you started any new meds in the past 6 months?" - This helps identify medication side effects that may cause weight loss.
D. "What foods have you eaten in the past 24 hours?" - This assesses dietary intake and nutritional status.
E. "Are you on a fixed income?" - Financial constraints can impact food choices and access to nutritious meals.
Summary:
B. "Do you watch TV while eating your meals?" - This does not directly address the potential reasons for weight loss in an older adult.
F. - No information given to evaluate this choice.
G. - No information given to evaluate this choice.
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Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Home health nurse is discussing dangers of food poisoning with client. Which info should nurse include in counseling? (Select all that apply.)
- A. Most food poisoning is caused by virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, and other dairy products
- D. Healthy people usually recover from illness in few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning.
C: Clients at risk should consume only pasteurized dairy products to avoid harmful bacteria. Unpasteurized dairy can contain pathogens.
E: Separating raw and fresh foods prevents cross-contamination, reducing the risk of foodborne illnesses.
Incorrect:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals may recover faster, typically within a few days, not weeks.
Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A, complete fall-risk assessment. This is the priority action because it helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (B) is important but assessing risk comes first. Completing a physical assessment (C) is also important but not the priority in this case. Surveying belongings (D) is not as urgent as assessing the client's fall risk.
Nurse has removed a sterile pack from its outside cover & placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. Unfolding this flap first ensures that the sterile contents inside the pack remain protected from contamination by the nurse's body and hands. Starting with the farthest flap minimizes the risk of accidental touching or contamination of the sterile instruments or supplies. Unfolding the closest flap (choice A) or the side flaps (choices B and C) first could potentially expose the sterile contents to contamination. Therefore, unfolding the flap farthest from the body is the most appropriate and logical step to maintain sterility and ensure safe patient care during the procedure.
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A: Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C: Turning pot handles toward the back of the stove reduces the risk of toddlers pulling them down. D: Placing safety gates across stairways prevents toddlers from falling down stairs. These strategies are crucial for accident prevention.
Incorrect choices: B: Keeping toilet seats up can lead to toddlers falling into the toilet. E: Making sure balloons are fully inflated increases the risk of choking hazards.