Nokea
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
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Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
- A. Ask an unlicensed assistive personnel to stay with the client.
- B. Place the bedpan within the reach of the client.
- C. Obtain a bedside commode for the client to use.
- D. Notify the healthcare provider of the client's concerns.
Correct Answer: C
Rationale: Commode prevents enema expulsion accidents.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
- A. Consult the palliative care team about the client's care.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Obtain a 'do not resuscitate' (DNR) prescription.
Correct Answer: C
Rationale: Clarifying 'heroic measures' ensures client wishes are understood.
History and physical
The client is a 28-year-old male who was admitted to the hospital for seizure medication adjustment. Has been having breakthrough seizures over the past month. Has a neurological disorder causing spasticity and limited ability to speak. Currently, has pain in the right leg of unexplained origin.
Nurses Notes
Administered seizure medication. Moved from chair to bed. Made a sound like moaning. Withdrew right leg from touch. Attempted to place leg in position of comfort but experienced muscle spasm. Facial grimacing
Flowsheet
Heart rate 102 beats/minute
The nurse is planning care for the client.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Assign a sitter to stay with the client;Have family stay at the bedside;Request antispasmodic medication;Request prescription for pain medication;Use objective symptoms to assess pain
- B. Chronic pain;Visceral pain;Referred pain;Acute pain
- C. Vital signs;Decrease in seizures;Response to pain medications;Joint mobility;Severity of muscle spasms
Correct Answer:
Rationale: Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.