NSG 452

The nurse case manager teaches the grandchild who is providing care for an elderly grandparent to monitor the client's dietary intake and report it to the dietitian on the home health care team. The nurse identifies the steps to use to record the client's dietary intake. Arrange the steps in the correct order for obtaining an accurate dietary intake record. All options must be used.

Determine the plates and containers that will be used for all meals. Determine each component of the meal plan. Record the recipe(s) used to make the meal. Photograph the prepared food plate. Photograph or otherwise document the food not eaten.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status exam?

Gathering mental status information during the health history interview is usually sufficient.

A woman brings her husband to a clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurses best course of action?

Complete a complete mental status examination

During a mental status examination, the nurse wants to assess a patients affect. The nurse should ask the patient which question?

How do you feel today?

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?

I never did too good in school.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse.

The nurse is assessing a 75yr-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this pt:

May take a little longer to respond, but his general knowledge & abilities should not have declined.

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:

More information should be gathered to decide whether her dress is appropriate.

A nurse has discovered a colleague pocketing a partial dose of an opioid despite documenting it as a waste. When confronted, the colleague acknowledges the behavior. What is the nurse's best action?

Report the colleague's actions because of legal and ethical obligations.

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.

Recall; After a 30min delay

When assessing a aging adult, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:

Sensory-Perceptive Abilities

During a mental status assessment, which question by the nurse would best assess a persons judgment?

Tell me what you plan to do once you are discharged from the hospital.

A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event?

The client may revoke or amend the terms of the advance directive.

The home health nurse is assessing a client and determines that the client has an unsteady gait. The client reports a history of falls. Which nursing action represents an advocacy role for the home health nurse?

contacting a health care equipment resource to rent a walker for the client to use

A client's spouse has expressed great concern about the fact that antibiotics have been prescribed for the treatment of pneumonia. The spouse states, "I do not trust all these pharmaceuticals. We are going to treat the pneumonia using the magnet therapy I read about online." What is the nurse's best response?

"It sounds like you have some important questions about the use of medication."

The nurse is assessing a client who is distraught after receiving a positive diagnosis for human immunodeficiency virus (HIV). The client states, "I am not ready to die." What is the nurse's best action?

Acknowledge the client's fears, and then explain the increasing survival times in HIV.

The nurse is assessing the mental status of a child. Which statement about children & mental status is true?

All aspects of mental status in children are interdependent.

During an examination, the nurse can assess mental status by which activity?

Observing the pt. & inferring health or dysfunction

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:

Will be oriented to place and person, but the patient may not be certain of the date.

Parents of an infant have told the nurse that they have decided not to have their child vaccinated. What is the nurse's best response?

"That must have been a difficult decision. What caused you to make that choice?"

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

Give pt. the four unrelated words test.

A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse?

Notify the health care provider about the concern for the prescribed dose.

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurses best approach regarding this examination is to:

Plan to defer the rest of the mental status examination

The nurse is admitting a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What actions will the nurse perform with planning and providing the client's care? Select all that apply.

Assign the client to a private room. Keep dedicated equipment in the client's room.

A home health care nurse is making an initial visit to a 68-year-old client who was recently discharged from a rehabilitation facility after experiencing a stroke. The client has significant left-sided weakness and needs assistance with dressing and hygiene. The client lives alone with a 68-year-old partner. The partner has chronic obstructive pulmonary disease (COPD) and uses oxygen intermittently. Assessment findings include vital signs within normal parameters and intact pink, moist skin. The client denies any problems with urinary and bowel elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply.

physical therapy occupational therapy home health aide