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The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A because the lack of electricity poses a serious risk to the patient's health and safety, affecting the ability to store and prepare food properly, maintain a comfortable temperature, and access medical devices if needed. Collaboration with social services is crucial to address this urgent issue. Choices B, C, and D do not directly impact the patient's immediate health needs and can be addressed at a later time.
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The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?
- A. The patient continues to get up from the chair at the nurses' station.
- B. The patient gets restless when the sitter leaves for lunch.
- C. The patient folds three washcloths over and over.
- D. The patient apologizes for being 'such a bother.'
Correct Answer: C
Rationale: The correct answer is C because the patient folding three washcloths over and over indicates engagement in a task, showing decreased restlessness or agitation. This behavior suggests the patient is able to focus on a repetitive and soothing activity, indicating successful use of alternatives to restraint. Choice A shows continued restlessness, choice B demonstrates dependence on the sitter, and choice D indicates the patient's emotional response, none of which directly reflect the effectiveness of the alternative intervention.
The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.)
- A. Water outdoor plants with a nozzle and hose.
- B. Walk to the mailbox in the summer.
- C. Encourage yearly eye examinations.
- D. Use bathtubs without safety strips.
- E. Keep pathways clutter free.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- B: Walking regularly helps maintain strength and balance, reducing fall risk.
- C: Yearly eye exams can detect vision problems that contribute to falls.
- E: Clear pathways prevent tripping hazards, reducing the risk of falls.
Incorrect Choices:
- A: Watering plants is unrelated to fall prevention.
- D: Bathtubs without safety strips increase fall risk.
- F, G: No additional choices given.
The patient is confused
- A. trying to get out of bed
- B. and pulling at the IV tubing. Which nursing diagnosis will the nurse add to the care plan?
- C. Impaired home maintenance
- D. Deficient knowledge
- E. Risk for poisoning
- F. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Deficient knowledge. The patient's confusion and behavior suggest a lack of understanding regarding the importance of staying in bed and not pulling at the IV tubing. By selecting this nursing diagnosis, the nurse can address the patient's cognitive deficits and provide education to prevent potential harm. Choice A is incorrect as it describes a behavior related to confusion, not a nursing diagnosis. Choice B focuses on the patient's actions rather than the underlying issue of knowledge deficit. Choices C, E, and F are not directly related to the patient's confusion and do not address the root cause of the behavior.
The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action?
- A. The patient removes the armband to bathe.
- B. The patient wears the red nonslip footwear.
- C. The patient insists on taking a 'water' pill in the evening.
- D. The patient who is allergic to penicillin asks the name of a new medicine.
Correct Answer: B
Rationale: Correct Answer: B - The patient wears the red nonslip footwear.
Rationale: The yellow armband typically signifies fall risk in healthcare settings. By wearing red nonslip footwear, the patient demonstrates understanding of the fall risk and the importance of preventing falls. This indicates a good comprehension of the armband's purpose and the need for safety precautions.
Other Choices:
A: The patient removing the armband to bathe does not demonstrate understanding of its significance in preventing falls.
C: Insisting on taking a 'water' pill in the evening is unrelated to the purpose of the yellow armband.
D: Asking about a new medicine when allergic to penicillin does not show understanding of the armband's purpose.
The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?
- A. Smoking even at parties is not good for my body.
- B. Our campus is safe; we leave our dorms unlocked all the time.
- C. As long as I have only two drinks, I can still be the designated driver.
- D. I am young, so I can work nights and go to school with 2 hours' sleep.
Correct Answer: A
Rationale: The correct answer is A: "Smoking even at parties is not good for my body." This statement indicates an understanding of the threats to adult safety as it acknowledges the harmful effects of smoking on one's health. Smoking increases the risk of various health problems, such as lung cancer and heart disease. By recognizing the negative impact of smoking, the group member shows an understanding of the importance of making healthy choices to ensure their safety and well-being.
Other choices are incorrect:
B: Leaving dorms unlocked poses a safety risk.
C: Even with two drinks, driving impairs judgment and reaction time.
D: Working nights with minimal sleep can lead to fatigue-related accidents.
In summary, choice A is correct as it demonstrates awareness of the health risks associated with smoking, while the other choices overlook potential safety threats.