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Despite numerous instructions, an elderly patient with Parkinson's disease is unable to administer ophthalmic medication without assistance due to hand tremors. What is the best course of action for the nurse?
- A. Continue to reinforce the instructions to boost the patient's self-confidence.
- B. Determine if a family member is available and willing to administer the medication.
- C. Obtain a prescription for a visiting nurse to administer the medication twice a day.
- D. Document the patient's inability to administer the medication without assistance.
Correct Answer: B
Rationale: If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.
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During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help. What action should the nurse take?
- A. Suggest that the patient get a walker.
- B. Encourage the patient to acquire a medical alert device.
- C. Ensure the patient's privacy while in the bathroom.
- D. Identify potential safety hazards in the home.
Correct Answer: D
Rationale: Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.
The nurse is triaging victims of a tornado at an emergency shelter. An adult who has been wandering and crying comes to the nurse. Which action should the nurse take?
- A. Check the client's temperature, blood sugar, and urine output.
- B. Arrange for the client to be transported for laboratory tests and an electrocardiogram (ECG).
- C. Delegate care of the crying client to an unlicensed assistant.
- D. Direct the client to the shelter's nutrition center to obtain water and food.
Correct Answer: D
Rationale: Directing the client to the shelter's nutrition center to obtain water and food is the best action in this situation. The client may be dehydrated or hungry, which could be contributing to their distress. Providing for these basic needs can help to calm the client and provide a sense of safety and stability.
A patient is admitted to the emergency department with symptoms resembling the flu. What information should the nurse gather to rule out exposure to anthrax spores?
- A. Determine the patient's occupation.
- B. Identify the patient's personal contacts over the past week.
- C. Obtain a twenty-four-hour diet history.
- D. Inquire about previous vaccination for smallpox.
Correct Answer: A
Rationale: Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. Certain occupations, such as those involving livestock or animal products, may increase the risk of exposure to anthrax spores.
A 42-year-old male client, who started experiencing mild flu-like symptoms 2 days ago, including an oral temperature of 101.2 °F (38.4 °C), came to the emergency department today due to increasing shortness of breath, cough, and chest pain. The client has no significant medical or surgical history. He occasionally drinks alcohol but denies smoking or drug use. He mentioned that he works in a government building and opened a package that was full of white powder. He may have inhaled some of the powder and coughed a few times but did not have any problems until a couple of days later. What actions should be taken?
- A. Apply oxygen via a nasal cannula.
- B. Place the client on a cardiorespiratory monitor.
- C. Infuse IV fluid boluses.
- D. Administer antiviral medication.
Correct Answer: B
Rationale: Given the client's symptoms and potential exposure to an unknown substance, it is crucial to monitor his vital signs and cardiorespiratory status. This will help healthcare providers detect any changes in the client's condition and respond appropriately.
The home health nurse assesses an older adult client and observes possible signs of abuse. Which resource should the nurse use to guide their decision regarding reporting these suspicions?
- A. American Nurses Association (ANA) Code of Ethics.
- B. Nursing procedure manual.
- C. State law.
- D. Nurse practice act.
Correct Answer: C
Rationale: State law often provides specific guidelines on how and when to report suspected elder abuse. Therefore, it would be the most appropriate resource for the nurse to use in this situation.