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A nurse is providing teaching about home safety to an adult child of an older adult client who is postoperative following knee replacement surgery.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
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A nurse is assessing a client following an esophagogastroduodenoscopy.
Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.
A nurse is caring for a client in an outpatient clinic.
Laboratory Results
First office visit:
Erythrocyte sedimentation rate (ESR) 21 mm/hr (up to 20 mm/hr)
Hct 36% (37 to 47%6)
Hgb 12 g/dL (12 to 16 g/dL)
WBC count 6000/mm³ (5,000 to 10,000/mm³)
Uric acid 6.1 mg/dL (2.7 to 7.3 mg/dL)
6-month follow-up:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Antinuclear antibodies (ANA) positive
Hct 35% (37 to 47%)
Hgb 11 g/dL (12 to 16 g/dL)
WBC 4000/mm³ (5,000 to 10,000/mm³)
Uric acid 6,3 mg/dL (2.7 to 7.3 mg/dL)
The client is at highest risk for developing--------- evidenced by the client's--------
- A. Rheumatoid arthritis
- B. decreased Hct and Hgb levels
- C. ESR level
- D. Systemic lupus erythematosus
- E. Anemia evidenced by the client's
- F. Gout evidenced
- G. decreased WBC count
Correct Answer: D,G
Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.
A nurse is admitting an older adult client who was transferred from another facility.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.