The nurse plans care for an older female resident of a nursing home who has experienced a sudden deterioration in visual acuity. Which intervention should the nurse complete first?
a. Prevent behavioral and social decline.
b. Tell her to hold rails during ambulation.
c. Examine her mood and functional status.
d. Use problem solving involving the resident.
C
Feedback
A Incorrect. Preventing decline can be a goal in the overall plan of care for this resident, but that cannot be determined until the assessment is complete.
B Incorrect. This is a potential nursing intervention for patient teaching; however, in problem solving, a different compensatory solution can be developed based on the assessment.
C Correct. The most important intervention for the nurse to complete first is to as-sess the impact of the visual impairment on the resident's quality of life, mood, and functional ability. The resulting assessment data provide the basis for solv-ing new problems caused by the loss of vision and finding compensatory me-chanisms for the resident.
D Incorrect. Problem solving takes place after a complete assessment.
You might also like to view...
The nurse is caring for a client who will be discharged with an indwelling catheter. The nurse has provided education to the client and family in regards to catheter care once the client is discharged
Which client or family action indicates a correct understanding of the information presented? A) Hanging the drainage bag on the towel rod B) Taking a shower each day instead of taking a tub bath C) Restricting the amounts of fluids per day D) Emptying the drainage bag twice a day
The nurse is instructing a pregnant client on wellness promotion for the developing fetus. The nurse should instruct the client that the developing baby is most vulnerable to noxious stimuli:
a. 12–16 weeks after conception. b. 2–8 weeks after conception. c. if born prematurely. d. at 20–24 weeks when circulation is visible.
The client says to the nurse, "I feel really close to you. You are the only true friend I have." The most therapeutic response the nurse can make is:
A) "I am sure there are other people in your life who are your friends; besides, we just met." B) "It makes me feel good that you trust me so much; it is important for the work we are doing together." C) "Since ours is a professional relationship, let's explore other opportunities in your life for friendship." D) "We are not friends. This is strictly professional."
When preparing to complete a competency examination involving a neurologic assessment in a simulation laboratory, the nurse reviews the critical elements, which consist of:
A) required criteria that must be incorporated into the assessment for the desired outcome. B) fundamental strategies unique to complex dynamic care environments. C) objective data that can be used to determine the likelihood that the client will recover. D) those steps that result in life or death of a client.