Nokea
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with finger foods for meals.
- B. Restrict visitors during meals.
- C. Limit snacks between meals.
- D. Provide the client with three large meals each day.
Correct Answer: A
Rationale: Finger foods enhance self-feeding and intake in dementia clients.
You may also like to solve these questions
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. So, you are upset about all of the recent changes on the unit?
- C. There has been too much complaining about these changes.
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Reflective listening acknowledges the AP’s feelings and encourages discussion.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Twist the catheter gently.
- C. Inflate the catheter's balloon.
- D. Lower the penis to a 45° angle.
Correct Answer: B
Rationale: Gently twisting the catheter may navigate past resistance, often due to the prostatic urethra.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Remind the nurse that only staff caring for the client may access the client's record.
- C. Complete an incident report about the breach of confidentiality.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: B
Rationale: Reminding about access rules upholds confidentiality standards.