Nokea
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
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The nurse should initiate discharge planning for a client
- A. When the client or family demonstrate readiness to learn self care modalities
- B. When informed that a date for discharge has been determined
- C. Upon admission to a hospital unit or the emergency room
- D. When the client's condition is stabilized on the assigned unit
Correct Answer: C
Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.
The nurse is evaluating how a client who has a halo brace is reacting to this change in his body image. Which statement by the client indicates a need for additional support in adjusting to the brace?
- A. I shall avoid going out in public since I may bump into people.'
- B. I don't mind that people look at me.'
- C. I told my grandchildren that this looks like a space helmet.'
- D. I like to sleep in the reclining chair that we have.'
Correct Answer: A
Rationale: Avoiding public interaction suggests poor adjustment to the halo brace, indicating a need for support to address body image concerns.
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
An adult who had a cerebrovascular accident (CVA) with expressive aphasia has started saying some words. The client's family is quite upset because the words are mostly profanity. They tell the nurse that the client usually does not use profanity. How should the nurse respond to the family?
- A. She must be in a lot of pain to use profanity. We will assess her for pain.'
- B. Many people who have had aphasia following a stroke use profanity when speech first returns. Other words will soon follow.'
- C. It is not appropriate for her to use profanity when speaking to the nurses. We will discipline her when this happens.'
- D. She must be upset with you or us. We will try to find out what is bothering her.'
Correct Answer: B
Rationale: Profanity in early expressive aphasia post-CVA is common due to disinhibition in damaged brain areas; reassuring the family that other words will follow is appropriate.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.