Nokea
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
- A. Take the resident to the toilet after meals
- B. Limit the amount of fruits and vegetables the client consumes
- C. Encourage the resident to drink fluids
- D. Take the resident for a walk around the unit several times a day
- E. Ask the resident to list his/her favorite foods
- F. Discourage snacking between meals
Correct Answer: A,C,D
Rationale: Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.
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A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
- A. An individual displays restlessness
- B. There are obvious signs of depression
- C. Conducting any health assessment
- D. The resident reports memory lapses
Correct Answer: C
Rationale: Conducting any health assessment. A mental status examination is a critical part of baseline health assessments.
The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to
- A. increase the amount of calcium in her daily diet.
- B. increase the amount of vitamin D in her daily diet.
- C. increase the amount of time she is exposed to sunlight.
- D. increase her activities that involve weight-bearing.
Correct Answer: D
Rationale: Weight-bearing activities stimulate bone formation, critical for osteoporosis, and improve mobility post-CVA. Options A, B, and C support bone health but are less impactful than exercise for addressing both conditions.
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
- A. Rotation of injection sites
- B. Insulin mixing and preparation
- C. Daily blood sugar monitoring
- D. Regular high protein diet
Correct Answer: C
Rationale: Daily blood sugar monitoring. Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.