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A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
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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.
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
- A. Drowsiness
- B. Gingival hyperplasia
- C. Skin rash
- D. Mild nausea
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (B) and mild nausea (D) are common side effects that do not require immediate reporting.
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the clients plan of care?
- A. Assess the PICC infusion system systematically.
- B. Flush the line only before infusing medication.
- C. Use a sterile dressing for the catheter site every 7 days.
- D. Allow the catheter to remain uncapped when not in use.
Correct Answer: A
Rationale: The correct answer is A: Assess the PICC infusion system systematically. This is essential to monitor for signs of infection, occlusion, or dislodgement of the catheter. Regular assessment can help identify any issues early and prevent complications.
Summary:
B: Flushing the line only before infusing medication is incorrect as regular flushing is necessary to maintain catheter patency.
C: Using a sterile dressing every 7 days is incorrect as the dressing should be changed according to facility protocol or if it becomes soiled or loose.
D: Allowing the catheter to remain uncapped when not in use is incorrect as it can increase the risk of contamination and infection.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.