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A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?
- A. "I won’t be able to shop for you today because I have to get home to my family."
- B. "I would be happy to do whatever I can to help you."
- C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then."
- D. "Let's look at some other resources to solve this problem."
Correct Answer: D
Rationale: The correct answer is D: "Let's look at some other resources to solve this problem." This response is appropriate because it acknowledges the client's needs while also maintaining professional boundaries. By exploring other resources, such as community services or family support, the nurse can help the client find a more suitable solution.
A: Incorrect. This response is unprofessional and does not address the client's needs.
B: Incorrect. While it shows willingness to help, it does not address the issue of professional boundaries.
C: Incorrect. This response does not offer a practical solution and may not be feasible for the client.
E, F, G: Irrelevant. No information is provided for these options.
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A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
- A. "Why would you want to put your partner's health at further risk?"
- B. "You will need to discuss your concerns about your partner's diet with the provider."
- C. "Everyone likes food from home, but it can delay your partner's recovery."
- D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive. Choice B is not the most appropriate response as it doesn't address the partner's request directly. Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?
- A. Acute pancreatitis
- B. Slowed breathing
- C. Nasal septum perforation
- D. Permanent short-term memory loss
Correct Answer: B
Rationale: Heroin depresses the central nervous system, leading to respiratory depression.
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
- A. Mental Status Examination (MSE)
- B. Brief Patient Health Questionnaire (Brief PHQ)
- C. Abnormal Involuntary Movements Scale (AIMS)
- D. Scale for Assessment of Negative Symptoms (SANS)
Correct Answer: A
Rationale: The correct answer is A: Mental Status Examination (MSE). A MSE is crucial to assess cognitive function, orientation, memory, attention, and other mental aspects in older adults with suspected cognitive disorders. It helps identify cognitive deficits and guide appropriate interventions. Brief PHQ (B) focuses on mood disorders, AIMS (C) evaluates movement disorders, and SANS (D) assesses negative symptoms in psychiatric disorders, which are not specific to cognitive disorders. In summary, the MSE is the most relevant tool for assessing cognitive functions in this scenario.
A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse’s assessment priority?
- A. Coping abilities
- B. Support systems
- C. Suicide risk
- D. Psychiatric history
Correct Answer: C
Rationale: The correct answer is C: Suicide risk. This is the priority assessment because the client is reporting symptoms of depression and anxiety, which are risk factors for suicide. Assessing suicide risk is crucial for ensuring the client's safety. Coping abilities (A) and support systems (B) are important, but assessing suicide risk takes precedence in this situation. Psychiatric history (D) may provide valuable information, but it is not the priority when the client is actively reporting symptoms of depression and anxiety.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
- A. "I can arrange for a female assistive personnel to do your personal hygiene care."
- B. "The nurse assigned to care for you is very capable and cares for other women in this situation."
- C. "Your doctor is a man, so it seems like this should not be a problem."
- D. "I can review the assignments and arrange for a female nurse to care for you."
Correct Answer: D
Rationale: The correct answer is D. The nurse manager should respect the client's wishes and arrange for a female nurse to care for her. This is important for the client's comfort and sense of safety. Option A only addresses personal hygiene care, not overall nursing care. Option B focuses on the nurse's capabilities, not the client's preferences. Option C is dismissive of the client's concerns and does not address the issue directly. It is essential to prioritize the client's feelings and choices in this sensitive situation.