Nokea
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
- A. Encourage the client to eat independently with utensils.
- B. Provide finger food at mealtime.
- C. Feed the client only pureed foods.
- D. Offer the client fluids only between meals.
Correct Answer: B
Rationale: The correct answer is B: Provide finger food at mealtime. This option is appropriate for a client with dementia as it promotes independence and encourages self-feeding, which can help maintain their dignity and autonomy. Finger foods are easy to handle and reduce the risk of frustration or confusion that may arise from using utensils. Encouraging self-feeding also helps stimulate cognitive function and maintain motor skills.
A: Encouraging the client to eat independently with utensils may be challenging and frustrating for someone with dementia.
C: Feeding the client only pureed foods may not be necessary if the client is able to eat regular food safely.
D: Offering fluids only between meals may lead to dehydration, especially for clients who may forget to ask for fluids when needed.
You may also like to solve these questions
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct answer is C (Aspirin) and E (Naproxen). Aspirin and Naproxen are both NSAIDs that can increase the risk of bleeding when taken with warfarin, which is an anticoagulant. The combination can lead to excessive anticoagulation and potential bleeding complications. Ferrous sulfate (A) does not interact significantly with warfarin. Echinacea (B) is an herbal supplement that may have interactions with some medications, but not warfarin specifically. Dextromethorphan (D) is a cough suppressant and does not have a significant interaction with warfarin. In summary, Aspirin and Naproxen should be avoided with warfarin due to the increased risk of bleeding, while the other options do not have significant interactions with warfarin.
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.
A nurse is assessing a clients understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?
- A. Proceed with obtaining the signature.
- B. Explain the procedure in detail.
- C. Contact the provider who will be performing the procedure.
- D. Have the client sign the form and address concerns later.
Correct Answer: C
Rationale: The correct answer is C: Contact the provider who will be performing the procedure. This is the best course of action because the provider is the most qualified individual to explain the procedure in detail and address any concerns the client may have. By involving the provider, the client can receive accurate and comprehensive information directly from the source. Proceeding with obtaining the signature (A) without ensuring the client's understanding can lead to potential legal and ethical issues. Explaining the procedure in detail (B) may not be sufficient if the client still has questions or concerns. Having the client sign the form and addressing concerns later (D) is not appropriate as it prioritizes paperwork over patient understanding and safety.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowlers position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Upper left quadrant
- D. Mid-epigastric area
Correct Answer: B
Rationale: The correct answer is B: Left lower quadrant. Diverticular disease commonly causes pain in the left lower quadrant due to inflammation or infection of the diverticula, small pouches that can develop in the colon wall. This area corresponds to the location of the descending and sigmoid colon, where most diverticula occur. Pain in the right lower quadrant (choice A) is more indicative of appendicitis. Upper left quadrant pain (choice C) is more likely related to conditions involving the spleen or stomach. Mid-epigastric pain (choice D) is typically associated with issues related to the stomach or pancreas.