Nokea
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
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Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. I already had my immunizations as a child, so I'm protected in that area.
- B. It's important to schedule routine healthcare visits even if I'm feeling well
- C. If I'm having any discomfort, I'll just go to an urgent care center
- D. If I'm feeling stressed, I will remind myself that this is something I should expect
Correct Answer: B
Rationale: The correct answer is B: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.
Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which client should be assigned to room closest to the nursing station?
- A. 43-year-old client post-op following laparoscopic cholecystectomy
- B. 61-year-old client being admitted for telemetry to rule out MI
- C. 50-year-old client post-op following open reduction internal fixation of ankle
- D. 79-year-old client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79-year-old client post-op following below-the-knee amputation should be assigned to the room closest to the nursing station for fall prevention. This is because this client may have mobility challenges and an increased risk of falls due to the recent surgery and potential use of assistive devices. Placing the client closer to the nursing station allows for closer monitoring and quicker assistance in case of any fall-related incidents.
Choice A is incorrect because a 43-year-old client post-op following laparoscopic cholecystectomy is not necessarily at an increased risk for falls related to mobility issues.
Choice B is incorrect as a 61-year-old client being admitted for telemetry to rule out MI is not specifically at a higher risk for falls compared to the client post-amputation.
Choice C is incorrect as a 50-year-old client post-op following open reduction internal fixation of the ankle may have mobility limitations, but the risk of falls is typically lower compared to a client post
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
- A. Each movement is repeated 5 times by the patient.
- B. Each movement is performed until the patient experiences pain.
- C. Each movement is completed quickly and smoothly by the nurse.
- D. Each movement is moved just to the point of resistance by the nurse.
Correct Answer: D
Rationale: The correct answer is D because moving each joint just to the point of resistance during passive ROM exercises helps prevent injury and avoids causing pain to the patient. Moving beyond the point of resistance can result in muscle strain or joint damage. This technique allows the nurse to safely improve joint mobility without causing harm.
Choice A is incorrect because the patient may not be able to repeat the movement 5 times due to their impaired mobility. Choice B is incorrect because continuing movement until the patient experiences pain is harmful and can lead to injury. Choice C is incorrect because moving quickly and smoothly may not allow the nurse to gauge the patient's tolerance and could potentially cause harm.
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.
Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group? (Select all that apply.)
- A. Install bath rails & grab bars in bathrooms
- B. Wear helmet while skiing
- C. Install carbon monoxide detector
- D. Secure firearms in safe location
- E. Remove throw rugs from the home
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Young adults are more likely to engage in risky activities like skiing, hence wearing a helmet (B) is crucial for head protection. Carbon monoxide exposure is a concern in any age group, so installing a detector (C) is important. Young adults may have access to firearms, making it vital to secure them in a safe location (D) to prevent accidents. Choices A and E are more relevant for older adults to prevent falls, while F and G are not provided in the question.