Nokea
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
- A. Report the family to family protective services.
- B. Congratulate the family on solving the problem.
- C. Help the family think of ways to make the environment safer for the client.
- D. Tell the family that they are not allowed to restrain the client with a leather belt.
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
You may also like to solve these questions
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
- A. Which symptom should the nurse expect initially in a client with a subdural hematoma and cerebral edema?
- B. Unequal and dilated pupils.
- C. Decerebrate posturing.
- D. Grand mal seizures.
- E. Decreased level of consciousness.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- A. I have constant blurred vision.
- B. I can't see on my left side.
- C. I have to turn my head to see my room.
- D. I have specks floating in my eyes.
Correct Answer: C
Rationale: I have to turn my head to see my room. Intraocular pressure becomes elevated, producing a progressive loss of the peripheral visual field in the affected eye.
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.
The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?
- A. A patient with a chest tube who is ambulating in the hall.
- B. A patient with a colostomy who requires assistance with an irrigation.
- C. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing.
- D. A patient who is refusing medication to treat cancer of the colon.
Correct Answer: D
Rationale: requires assessment skills of the RN