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A nurse delegating ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. Client ambulates with slippers over antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain medication 30 min ago
- E. Client is allergic to codeine
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure proper footwear and prevent falls. Sharing that the client uses a front-wheeled walker when ambulating (C) is vital for safety and stability. Informing the AP that the client had pain medication 30 minutes ago (D) is crucial to prevent overexertion and ensure appropriate monitoring for side effects. Choice A is incorrect because the roommate's independence is not relevant to the client's ambulation. Choice E is also incorrect as the client's allergy to codeine is not directly related to ambulation delegation.
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A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers for fussiness and loose stools.
C: Asking about a specific food can pinpoint the culprit causing the symptoms.
D: Vomiting could indicate a more serious issue, so this question helps assess the severity of the symptoms.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding more foods could worsen the issue.
E: Making a generalization about how babies react to new foods is not helpful in this specific case.