Nokea
You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?
- A. Teach the daughter instead
- B. Teach both and ask the daughter to translate for you
- C. Contact a home health agency to provide care
- D. Provide a pamphlet with detailed instructions
Correct Answer: B
Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.
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You are caring for a group of elderly clients, many of whom are affected by multiple chronic disorders and are also, at times, affected by some acute disorders that require medical and nursing attention. As you are caring for these clients, some will need a new medication regimen for an acute disorder. You should consider the fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity due to the elderly having a(n):
- A. Increased creatinine clearance.
- B. Impaired immune system.
- C. Decreased hepatic metabolism.
- D. Increased bodily fat
Correct Answer: C
Rationale: The correct answer is 'Decreased hepatic metabolism.' The elderly population is at risk for more side effects, adverse drug reactions, and toxicity due to a decrease in hepatic metabolism. This is caused by changes in hepatic functioning in the elderly, including decreased hepatic blood flow and functioning. Choice A, 'Increased creatinine clearance,' is incorrect as aging typically results in decreased, not increased, creatinine clearance. Choice B, 'Impaired immune system,' is not directly related to the increased risk of adverse drug reactions in the elderly. Choice D, 'Increased bodily fat,' is not a primary factor contributing to the increased risk of medication-related issues in the elderly population.
A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?
- A. Explain the adverse effects the client might experience from the treatment
- B. Verify the client gave consent voluntarily for the treatment
- C. Describe the benefits of the treatment to the client
- D. Outline possible alternatives to the treatment for the client
Correct Answer: B
Rationale: When obtaining informed consent for a procedure like electroconvulsive therapy, the nurse's primary responsibility is to ensure that the client has given consent voluntarily and is capable of making such a decision. While it is essential to provide information on the treatment's benefits, risks, and alternatives, the priority is to verify the client's voluntary consent. Explaining the adverse effects and describing the benefits are important steps in the informed consent process, but the critical step is to confirm the client's voluntary agreement. Outlining possible alternatives to the treatment is also important but comes after ensuring the client's voluntary consent.
A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?
- A. Patients sleep better with the lights dimmed.
- B. The nightshift nurses prefer to work with less light.
- C. It's time for him to sleep, and you should, too.
- D. There's a reason we do that. Let me share a research study with you.
Correct Answer: D
Rationale: The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care. Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.
A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?
- A. Encourage the client to participate in group therapy on the unit.
- B. Initiate one-to-one observation of the client.
- C. Focus the client on reality.
- D. Notify the provider of the client's statement.
Correct Answer: B
Rationale: When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
- A. To tell the client this is not true; that we all have a purpose in life.
- B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
- C. To reassure the client that you know how the client is feeling and that things will get better.
- D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.