Nokea
The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.
You may also like to solve these questions
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
- A. Bradycardia
- B. Nausea
- C. Hypertension
- D. Urticaria
- E. Stridor
Correct Answer: B, D, E
Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.
A school nurse is teaching bicycle safety to a group of school-age children. Which of the following statements by a child indicates an understanding of the teaching?
- A. I should walk my bicycle through crosswalks.
- B. I should keep my bicycle far away from the curb.
- C. I should ride my bicycle side-by-side when biking with a friend.
- D. I should ride my bicycle in the opposite direction of the traffic flow.
Correct Answer: A
Rationale: The correct answer is A: "I should walk my bicycle through crosswalks." This statement indicates an understanding of the teaching because it shows awareness of pedestrian rules at crosswalks, emphasizing safety when not riding the bicycle. Walking the bicycle through crosswalks ensures visibility to drivers and prevents accidents.
Summary:
B: Keeping the bicycle far from the curb increases the risk of colliding with vehicles or obstacles.
C: Riding side-by-side is unsafe as it can obstruct traffic and increase the chances of accidents.
D: Riding in the opposite direction of traffic flow is dangerous and against traffic laws, increasing the risk of head-on collisions.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wash my hands for 10 seconds with hot water after working in the garden.
Correct Answer: B
Rationale: The correct answer is B: I can visit my nephew who has chickenpox 5 days after the sores have crusted. This answer demonstrates understanding of infection prevention because chickenpox is contagious until the sores have crusted over completely. Visiting the nephew after this period reduces the risk of contracting the virus.
Incorrect answers:
A: Taking antibiotics for a virus is ineffective as antibiotics only work against bacterial infections.
C: Cleaning a cat's litter box can expose the client to toxoplasmosis, a harmful parasite during pregnancy.
D: Washing hands for only 10 seconds with hot water is insufficient for proper hand hygiene; CDC recommends washing for at least 20 seconds.
A school nurse is implementing health screening. Which of the following assessment findings should the nurse recognize as the highest priority?
- A. A child who has a BMI of 18
- B. An adolescent who has scoliosis
- C. An adolescent who has psoriasis
- D. A child who has nits
Correct Answer: B
Rationale: The correct answer is B: An adolescent who has scoliosis. Scoliosis is a spinal deformity that can progress and cause serious health issues if left untreated. The school nurse should prioritize this assessment finding to ensure early detection and appropriate interventions to prevent further complications. A: A child with a BMI of 18 may indicate underweight but is not as urgent as scoliosis. C: Psoriasis is a skin condition that may require management but is not immediately life-threatening. D: Nits (lice eggs) are a common issue but do not pose a significant health risk compared to scoliosis.
A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus. Which of the following actions should the nurse take?
- A. Remove fresh flowers from the client's home
- B. Wear a mask when within 3 feet of the client
- C. Encourage the client to use a HEPA filter in the house
- D. Double bag soiled dressing in polyethylene bags
Correct Answer: D
Rationale: The correct answer is D: Double bag soiled dressing in polyethylene bags. This is important to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) to others. Double bagging the soiled dressing in polyethylene bags helps contain the bacteria and reduces the risk of transmission.
Choice A: Removing fresh flowers is not directly related to preventing the spread of MRSA.
Choice B: Wearing a mask within 3 feet of the client may not be effective in preventing MRSA transmission.
Choice C: Using a HEPA filter is not specifically targeted at preventing MRSA transmission.
In summary, choice D is correct because it directly addresses the prevention of MRSA transmission, while the other choices are not as directly related to this specific concern.