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. Limit snacks between meals.
- B. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.
You may also like to solve these questions
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Prepare the client for surgery with implied consent.
- D. Postpone the procedure until the staff contacts the guardian.
Correct Answer: C
Rationale: Implied consent applies in emergencies when delay risks life, and the guardian is unavailable.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. BMI of 24
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. Orthostatic hypotension
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular complications.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. Unnecessary sterile items are placed on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- D. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle, breaching sterility.
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
At 1000 the nurse enters the client's room. The first action the nurse should take is followed by
- A. Remove the pillows
- B. Turn the client to their side
- C. call for emergency assistance
- E. initiate IV fluids
- F. document seizure
- G. prepare medications
Correct Answer: A,B
Rationale: Removing pillows prevents airway obstruction; turning to the side aids drainage during a seizure.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.