Nokea
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 G sodium diet, Restraint as needed, Limit fluids to 1800 mL daily, Continue antihypertensive medication, Milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should:
- A. Question the fluid restriction.
- B. Question the order for restraint.
- C. Transcribe the prescriptions as written.
- D. Assess the resident’s bowel elimination
Correct Answer: A
Rationale: Step 1: Fluid restriction of 1800 mL may not be appropriate for all residents in a skilled nursing facility. Step 2: Excessive fluid restriction can lead to dehydration, especially in elderly residents. Step 3: It is crucial for the nurse to question the fluid restriction to ensure it is safe for the resident. Therefore, the correct answer is A.
Summary:
- Option A is correct as questioning the fluid restriction is essential for the resident's safety.
- Option B is incorrect as restraining a resident should only be used as a last resort and should be questioned if not necessary.
- Option C is incorrect as blindly transcribing without assessing appropriateness can be harmful.
- Option D is incorrect as assessing bowel elimination is important but addressing the fluid restriction is more urgent in this scenario.
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A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, Encourage patient to attend one psychoeducational group daily?
- A. Assessment
- B. Implementation
- C. Analysis
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves putting the plan of care into action. Encouraging the patient to attend a psychoeducational group daily is an action that is carried out as part of the plan to build social skills. This step focuses on executing interventions to achieve the desired outcomes. In contrast, assessment (A) involves collecting data, analysis (C) involves interpreting data, and evaluation (D) involves determining the effectiveness of interventions. Therefore, the correct placement for recording this item is in the implementation phase.
The spouse of a patient recently diagnosed with early-stage Alzheimer's disease asks, "Is there anything I can do to help delay the progression of this disease?" Which strategy has the greatest potential for preserving the protective abilities of immune cells related to the disease?
- A. Minimize contact with the public during cold and flu season.
- B. Enroll the patient in an exercise program that meets regularly.
- C. Provide supplements to enhance the patient’s immune system.
- D. Identify creative ways to keep the patient mentally challenged.
Correct Answer: B
Rationale: The correct answer is B: Enroll the patient in an exercise program that meets regularly. Regular exercise has been shown to have numerous benefits for brain health, including improving cognitive function and reducing the risk of cognitive decline. Exercise also helps in maintaining a healthy immune system by promoting the circulation of immune cells throughout the body. This can help support the protective abilities of immune cells related to Alzheimer's disease.
Minimizing contact with the public during cold and flu season (Choice A) may reduce the risk of infections but does not directly address immune cell function. Providing supplements to enhance the patient's immune system (Choice C) may not be supported by scientific evidence and can potentially have adverse effects. Identifying creative ways to keep the patient mentally challenged (Choice D) is beneficial for cognitive health but does not directly target immune cell function as effectively as regular exercise.
A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action?
- A. Report the findings to the health care provider.
- B. Assess the patient for a history of renal problems.
- C. Assess the patient’s family history for cardiac problems.
- D. Arrange for the patient’s hospitalization on the psychiatric unit.
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Reporting the findings to the health care provider is the next best action because elevated BUN and creatinine levels indicate possible renal dysfunction, which could be causing the psychiatric symptoms. The health care provider needs this information to determine appropriate treatment and further evaluation.
Summary of Incorrect Choices:
B: Assessing the patient for a history of renal problems is not the next best action because the lab results already indicate potential renal issues.
C: Assessing the patient’s family history for cardiac problems is irrelevant to the elevated BUN and creatinine levels and the psychiatric symptoms.
D: Arranging for the patient’s hospitalization on the psychiatric unit is premature without addressing the underlying medical issue indicated by the lab results.
The highest priority for assessment by nurses caring for older adults who self-administer medications is:
- A. Use of multiple drugs with anticholinergic effects.
- B. Overuse of medications for erectile dysfunction.
- C. Missed doses of medications for arthritis.
- D. Trading medications with acquaintances.
Correct Answer: A
Rationale: The correct answer is A: Use of multiple drugs with anticholinergic effects. This is the highest priority as anticholinergic medications can have severe side effects in older adults, including confusion, constipation, and increased risk of falls. Nurses need to assess for potential harm caused by these medications.
Choice B (Overuse of medications for erectile dysfunction) is not the highest priority as it may not pose an immediate threat to the health and safety of older adults compared to anticholinergic effects.
Choice C (Missed doses of medications for arthritis) is important but not as critical as assessing for the potential harm caused by anticholinergic medications.
Choice D (Trading medications with acquaintances) is concerning but not as urgent as assessing for the harmful effects of anticholinergic medications, which can lead to serious health complications.
Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.