Nurse reviewing CDC's immunizations recommendations with mid...

Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)

A. Haemophilus influenzae type b
B. Varicella
C. Herpes zoster
D. HPV
E. Seasonal influenza

Correct Answer: B,C,E

Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? Select all that apply

A. One family member has gone to lunch.
B. Patient is placed in bilateral wrist restraints at 0815.
C. Bilateral radial pulses present, 2+, hands warm to touch
D. Straps with quick-release buckle attached to bed side rails
E. Attempts to distract the patient with television are unsuccessful.
F. Released from restraints, active range-of-motion exercises completed.

Correct Answer: B, C, E, F

Rationale: The correct answers are B, C, E, and F.

B: Documenting the time and type of restraints applied is essential for monitoring and ensuring proper care.
C: Assessing and documenting the patient's radial pulses and skin temperature in restraints is crucial to monitor circulation and skin integrity.
E: Documenting unsuccessful attempts to distract the patient with television helps identify alternative strategies for patient management.
F: Documenting the release from restraints and completion of range-of-motion exercises ensures proper follow-up care and monitoring.

Incorrect choices:
A: Not relevant to the patient's care in restraints.
D: Describes the equipment used but does not provide information on the patient's condition or care.

A nurse delegating ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?

A. The roommate is up independently
B. Client ambulates with slippers over antiembolic stockings
C. Client uses front-wheeled walker when ambulating
D. Client had pain medication 30 min ago
E. Client is allergic to codeine

Correct Answer: B,C,D

Rationale: The correct answer is B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure proper footwear and prevent falls. Sharing that the client uses a front-wheeled walker when ambulating (C) is vital for safety and stability. Informing the AP that the client had pain medication 30 minutes ago (D) is crucial to prevent overexertion and ensure appropriate monitoring for side effects. Choice A is incorrect because the roommate's independence is not relevant to the client's ambulation. Choice E is also incorrect as the client's allergy to codeine is not directly related to ambulation delegation.

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?

A. Moves patient's arm in a full circle
B. Moves patient's arm across the body as far as possible
C. Moves patient's arm behind body, keeping elbow straight
D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed

Correct Answer: D

Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.

Nurse caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)

A. Place belt restraint on him when he's sitting on bedside commode
B. Keep bed in low position with full side rails up
C. Ensure client's call light is within reach
D. Provide client with nonskid footwear
E. Complete fall-risk assessment

Correct Answer: C,D,E

Rationale: Correct Answer: C, D, E

Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.

Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.

Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?

A. I'm struggling to accept my parents are aging & need so much help
B. It's been so stressful for me to think about having intimate relationships
C. I know I should volunteer my time for good cause, but maybe I'm just selfish
D. I love my grandchildren, but my son expects me to relive my parenting days

Correct Answer: B

Rationale: The correct answer is B: It's been so stressful for me to think about having intimate relationships. This issue should be prioritized for more assessment and intervention because difficulties with intimate relationships can significantly impact one's mental and emotional well-being. It may indicate underlying issues such as fear of intimacy, past trauma, or self-esteem issues. Addressing these issues can help improve overall quality of life.

Choice A is not the priority as accepting aging parents is a common life transition and may not have an immediate negative impact on mental health. Choice C, feeling selfish for not volunteering, is important but may not be as urgent as addressing intimate relationship stress. Choice D, feeling pressured by son about grandparenting, is important but may not directly affect the individual's mental well-being.