Nokea
Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
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A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client,If you don't eat I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?"
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault refers to the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client constitutes a threat of physical harm, which falls under the definition of assault. The nurse should intervene to prevent any potential harm to the client. The other choices are incorrect because: A: Battery involves actual harmful or offensive contact, which has not occurred in this situation. C: Negligence refers to a failure to provide reasonable care, not a threat of harm. D: Malpractice involves professional negligence or misconduct, which is not demonstrated in this scenario.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.
Which of the following actions should the nurse plan to take?
- A. Flush the NG tube with 30 ml D.9% sodium chloride before and after medication.
- B. Maintain the head of the bed at a 20° angle.
- C. Advance the rate of the feeding every 2 hr.
- D. Measure gastric residual volumes every 4 hr
Correct Answer: D
Rationale: Measuring residuals prevents aspiration risks.
Which of the following actions should the nurse take? Select all that apply.
- A. Vaginal culture
- B. Urine culture
- C. Obtain provider prescription for antibiotics
- D. Ibuprofen 660 mg every& hi for mid to moderate pain
- E. Obtain provider prescription for phenazopyridine
Correct Answer: B,C,E
Rationale: The correct actions for the nurse to take are B, C, and E. B, Urine culture, is important to identify the causative organism of a urinary tract infection. C, Obtaining a provider prescription for antibiotics, is necessary to treat the infection. E, Obtaining a provider prescription for phenazopyridine, can help alleviate urinary discomfort.
Choice A, Vaginal culture, is not relevant to the scenario of a urinary tract infection. Choice D, Ibuprofen for pain, is not addressing the infection itself. Without a prescription, phenazopyridine should not be administered.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.