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Nurse caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.
Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.
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A nursing instructor is reviewing actions nurses can initiate without a provider's prescription. Which of the following are nurse-initiated?
- A. Give morphine 1-2 mg IV every 1h as needed
- B. Insert NG tube to relieve gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C,D,E
Rationale: The correct answers are C, D, and E. C: Nurses can educate clients on progressive muscle relaxation techniques without a prescription to promote relaxation. D: Providing daily baths is part of basic hygiene care and can be initiated by nurses without a prescription. E: Repositioning clients every 2 hours to prevent pressure ulcers is within the scope of nursing practice. A: Administering morphine requires a prescription due to the potential for adverse effects. B: Inserting an NG tube involves a medical procedure and should be prescribed by a provider.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
A nurse caring for a client with a new prescription checks the electronic database for medication information. Which component of critical thinking is the nurse using?
- A. Knowledge
- B. Experience
- C. Intuition
- D. Competence
Correct Answer: A
Rationale: The correct answer is A: Knowledge. Checking the electronic database for medication information involves accessing and utilizing factual information and data, which is a key component of knowledge in critical thinking. This process requires the nurse to gather relevant information, analyze it, and apply it to make informed decisions. Experience (B) and competence (D) are related to skills and proficiency but do not specifically focus on accessing information. Intuition (C) involves a gut feeling or instinct, which is different from actively seeking and using information.
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.)
- A. Develop acceptance of diminished strength & increased dependence on others
- B. Feel frustrated that time is too short for trying to start another life
- C. Welcome opportunities to be creative & productive
- D. Commit to finding friendship & companionship
- E. Become involved in community issues & activities
Correct Answer: C,E
Rationale: The correct choices, C and E, align with Erikson's theory of psychosocial development for middle adulthood. Choice C, "Welcome opportunities to be creative & productive," reflects Erikson's stage of generativity versus stagnation, where individuals in middle adulthood seek to contribute to society and leave a legacy. Choice E, "Become involved in community issues & activities," relates to the desire for social involvement and making a positive impact on the community. Choices A, B, and D are incorrect because they do not align with the typical capabilities of middle adults according to Erikson's theory. Choice A contradicts the idea of middle adults striving for independence and self-reliance, while choice B reflects feelings of regret or despair, which are more characteristic of Erikson's later stages. Choice D, while important, does not capture the full scope of middle adulthood psychosocial development as outlined by Erikson.
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.