Nokea
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
- A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- B. Notify the healthcare provider and request a prescription for a large-volume enema.
- C. Assess the client's medical record to determine the client's normal bowel pattern.
- D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct Answer: C
Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option A) or increasing fluids (Option D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option B) is premature without understanding the client's baseline. Therefore, assessing the client's medical record is the priority before proceeding with any interventions.
You may also like to solve these questions
The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
- A. Low serum albumin level
- B. Low serum transferrin level
- C. High hemoglobin level
- D. High cholesterol level
Correct Answer: A
Rationale: Long-term protein deficiency significantly lowers serum albumin levels. Albumin, derived from protein breakdown, is produced by the liver when adequate amino acids are available. Due to its long half-life, acute protein loss minimally affects serum albumin levels. In contrast, serum transferrin, with a shorter half-life of 8 to 10 days, decreases with acute protein deficiency and is not a reliable indicator of chronic protein malnutrition. Elevated hemoglobin levels may occur in conditions like dehydration or chronic obstructive pulmonary disease, making it an unreliable indicator of chronic protein malnutrition. High cholesterol levels are not directly linked to protein malnutrition and do not serve as a reliable indicator. Therefore, the most reliable indicator of chronic protein malnutrition among the options provided is a low serum albumin level.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
- A. Take a vitamin supplement tablet once a day.
- B. Change positions in the chair at least every hour.
- C. Increase daily intake of water or other oral fluids.
- D. Purchase a newer model wheelchair.
Correct Answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
- A. Provide the client with a list of reliable internet sites that offer information on medications.
- B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
- C. Reassure the client that information about the medication is included in the written instructions.
- D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.
Correct Answer: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretive Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
- A. Determine how well the client can change the dressing.
- B. Ask the client to demonstrate the procedure.
- C. Seek a family member's opinion on the client's dressing change ability.
- D. Observe the client change the dressing unassisted.
Correct Answer: D
Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.