PN Funds QUIZ-hard

A nurse in a long term facility is attending to a group of clients. one of the clients is walking in the hallway, bumping into walls, and not responding to his name. which action should the nurse perform first?

Accompany the client back to his room. the nurse should apply the safety and risk-setting framework, which assigns priority to the factor or situation posing the greatest risk to the client.

A nurse is collecting data from a client. which of the following findings should the nurse identify as an indication of protein-calorie malnourishment?

- Dry, brittle hair - edema - poor wound healing adequate wound healing depends on ingestion of sufficient protein, calories, water, vitamins (especially C and A), iron, and zinc.

a nurse is planning a community presentation for young adults. which of the following behaviors should the nurse suggest incorporating into the presentation as part of Erikson's expected developmental task for this age group?

Adjusting to living with a partner. Erikson's developmental task for young adults is Intimacy vs. Isolation.

during a physical examination of a client, the nurse suspects strabismus. which of the following test should the nurse use to collect additional data?

Corneal light reflex this test will indicate the alignment of the client's eyes as well as any deviation inward or outward. with strabismus, the eyes will NOT align when the client focuses.

a nurse is caring for a client who is dehydrated. which lab values should the nurse expect from the client?

Hct 55% elevated hematocrit indicates dehydration. other manifestations include a weak pulse, tachycardia, hypotension, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

a nurse is collecting data of a client's peripheral vascular system. which of the following location should the nurse palpate the posterior tibial pulse?

below the medial malleolus the nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus of the inner surface of the client's ankle.

A nurse is caring for a client who requires a protective environment. which precaution should the nurse implement for this client?

make sure the client wears a mask when outside his room. clients who require protective environment have a compromised immune system, increasing the risk of infection. this client will need protection from breathing any harmful microorganisms in the environment.

A nurse is caring for a client in a long term facility. which of the following findings should alert the nurse to the possibility that the client has developed delirium?

reduced level of consciousness when a client has delirium. the nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances.

A nurse is evaluating a client's use of crutches. the nurse should identify that which of the following actions by the client indicates safe usage of his equipment?

the client has slightly flexed elbows when ambulating with crutches. the client should have slightly flexed elbows when ambulating with crutches. this allows the client to bear weight on the hands and not on the axillae.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take?

Insert the tip of the tubing 8cm (3.1 in) the nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "my child has suddenly become disinterested in certain foods." which of the following statements should the nurse make?

Keep a diary of the foods your child eats each day. the nurse should encourage the parent to keep a diary of the foods the child eats throughout the day 1 week. when they eat less at a meal, they can compensate by eating more at another meal or by having a snack.

A nurse is reinforcing teaching with a client regarding protein shake. which of the following foods should the nurse include as an example of an incomplete protein?

Lentils examples of incomplete proteins includes lentils, vegetables, grains, nuts, and seeds. complete proteins are eggs, soybeans, and yogurt.

A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long term facility. using this scale, which of the following parameters should the nurse evaluate? Incontinence mental state nutrition general physical condition

NUTRITION Nutrition, sensory perception, moisture, mobility, and friction and shear are the parameters of Braden scale for determining a client's risk for developing pressure ulcers

A nurse is reinforcing teaching with a client about the use of a straight-legged cane. which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side. the nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability.