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A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should
- A. question the fluid restriction.
- B. question the order for restraint.
- C. transcribe the prescriptions as written.
- D. assess the resident's bowel elimination.
Correct Answer: B
Rationale: The correct answer is B: question the order for restraint. Restraints should only be used as a last resort due to the potential risks and ethical considerations. In this scenario, the prescription of restraint seems unnecessary and should be questioned to ensure the resident's safety and well-being. The other choices are incorrect because questioning the fluid restriction (A) is not necessary as it aligns with the resident's needs, transcribing the prescriptions as written (C) would be inappropriate without considering the necessity of each order, and assessing the resident's bowel elimination (D) is important but not the immediate concern indicated by the order for restraint.
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A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's cognitive impairment is most consistent with:
- A. Delirium
- B. Dementia
- C. Sundown syndrome
- D. Early-onset Alzheimer disease
Correct Answer: A
Rationale: The correct answer is A: Delirium. Delirium is characterized by acute onset, fluctuating course, altered level of consciousness, and cognitive impairment. In this case, the patient's alternating sensorium and agitation suggest an acute confusional state, which is typical of delirium. Delirium is often caused by underlying medical conditions, medications, or substance abuse.
Summary of other choices:
B: Dementia is a chronic, progressive cognitive decline that does not typically present with acute onset and fluctuating symptoms like delirium.
C: Sundown syndrome refers to worsening of symptoms in the evening and is often seen in patients with dementia, not in this acute and fluctuating presentation.
D: Early-onset Alzheimer's disease is a form of dementia that typically has a more insidious onset and does not present with acute fluctuations in cognition like delirium.
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
- A. The child attends school regularly.
- B. The child is observed playing calmly.
- C. The father rarely speaks during nurse visits.
- D. The mother corrects negative comments by the child.
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities.
B: Playing calmly does not necessarily indicate overall improvement in the child's situation.
C: The father's silence during nurse visits does not directly reflect the child's well-being or progress.
D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
The nurse is evaluating a patient with bulimia nervosa. The most appropriate action is to:
- A. Assign a strict dietary plan to prevent weight gain.
- B. Monitor the patient for physical symptoms of starvation.
- C. Encourage the patient to avoid purging after meals.
- D. Provide emotional support without focusing on food-related behaviors.
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to avoid purging after meals. This is the most appropriate action because it addresses the harmful purging behavior associated with bulimia nervosa. By encouraging the patient to avoid purging, the nurse can help prevent serious health consequences such as electrolyte imbalances and damage to the esophagus.
Option A is incorrect because assigning a strict dietary plan may exacerbate the patient's unhealthy relationship with food and contribute to feelings of guilt and shame. Option B is incorrect as monitoring for physical symptoms of starvation may not directly address the underlying issue of purging behavior. Option D is also incorrect as providing emotional support alone may not effectively address the harmful purging behavior.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, 'I get lonely and drink a little to help me forget.' Select the nurses most therapeutic intervention.
- A. Assess whether this patient is drinking and driving
- B. Advise the person not to drink alone because the risks for injury increase
- C. Teach the person about risks for alcoholism and suggest other coping strategies
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults
Correct Answer: D
Rationale: This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
- A. The patient's vital signs
- B. Consent signed by the patient
- C. Supervision and credentials of the examiner
- D. Storage location of the patient's personal effects
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.