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A nurse has identified one of her clients as being at risk for social isolation. Which of the following interventions are most appropriate for this nursing diagnosis? (Select all that apply.) Move the client to a quiet area to reduce distractions Ask the client to identify troublesome feelings, such as loneliness or anxiety Encourage the client to lead a support group for others who are also lonely Place the client in a room with a roommate who has similar interests Encourage the client's family or significant other to visit frequently

Ask the client to identify troublesome feelings, such as loneliness or anxiety Place the client in a room with a roommate who has similar interests Encourage the client's family or significant other to visit frequently The client at risk of social isolation may have feelings of loneliness, a lack of social support, or being rejected; he or she may be more likely to withdraw from activities and may continue to reduce social interactions without some success in relationships. The nurse should encourage the client to verbalize feelings and to become more involved in situations where he or she is able to meet others and interact.

The nurse is preparing to discharge an 80-year-old client who has a new prescription for warfarin (Coumadin) for deep vein thrombosis. Which of the following instructions should be included in the nurse's discharge teaching? Follow a healthy diet by increasing green, leafy vegetables Take herbal remedies to manage cold symptoms Avoid alcohol due to enhanced anticoagulant effect Take Coumadin only on an empty stomach

Avoid alcohol due to enhanced anticoagulant effect Alcohol can increase the anticoagulant effect of warfarin and should be avoided.

After a nurse performs a mental status examination on an older adult, the previously cooperative client becomes silent when asked to spell "world" backwards. Which response by the nurse is most appropriate at this time? Discontinue assessing the client Go on to another mental assessment Assume the client has early signs of dementia Presume the client is functionally illiterate

Go on to another mental assessment After allowing sufficient time for a response, moving on to another area of assessment shows respect for the client; however, the nurse must document the lack of response in the client's assessment.

A nurse is caring for a client at risk for falling. Which of the following components are part of a fall risk assessment? (Select all that apply). Level of consciousness Heart rate Elimination status Gait and ambulation Respiratory rate

Level of consciousness Elimination status Gait and ambulation Fall risk is assessed by identifying conditions that can contribute to the client's risk of falling and subsequent injury. A checklist or designated assessment form can be used, in accordance with the facility policy. Components of a fall risk assessment include the client's level of consciousness, elimination status, gait and ambulation abilities, presence of orthostatic hypotension, and vision status.