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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 preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client?
- A. Encourage client to participate actively in learning
- B. Select instructional materials appropriate for older adult
- C. Identify goals nurse & client can agree are reasonable
- D. Determine what client knows about stress incontinence
Correct Answer: D
Rationale: The correct answer is D because determining what the client already knows about stress incontinence is essential for tailoring the instructional session effectively. By assessing the client's existing knowledge, the nurse can avoid repeating information that the client already understands and focus on areas where the client needs more education. This approach ensures that the session is individualized and meets the client's specific needs. Encouraging active participation (choice A) and setting goals (choice C) can come after assessing the client's knowledge. Selecting appropriate materials (choice B) is important but should be based on the client's knowledge level.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.
Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water
- B. Once my baby can sit up, he should be safe in bathtub
- C. I will test the temp of water before placing baby in bath
- D. Once my infant starts to push up, I will remove mobile from over the bed
Correct Answer: B
Rationale: The correct answer is B. This statement indicates a need for further teaching because it is not safe to leave a baby unattended in the bathtub even if they can sit up. Babies can easily slip or move unexpectedly, leading to a potential drowning risk. Teaching should emphasize the importance of constant supervision during bath time. Choice A is incorrect as it highlights an unsafe practice of initiating swimming lessons too early for an infant. Choice C demonstrates proper safety measures by testing water temperature. Choice D shows awareness of removing potential hazards from the infant's environment.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,
A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling?
- A. Carbon monoxide has distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with Hgb in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with Hgb in the body. Carbon monoxide is a colorless and odorless gas, so it does not have a distinct odor (choice A). Water heaters should be inspected annually, not every 5 years (choice B). Carbon monoxide poisoning affects the blood's ability to carry oxygen, not the lungs directly (choice C). By binding with hemoglobin, carbon monoxide reduces the blood's oxygen-carrying capacity, leading to tissue hypoxia and potentially fatal consequences. Therefore, it is crucial for the nurse to emphasize this information during counseling to help the client understand the serious implications of carbon monoxide exposure.