An 88-year-old female client with osteoporosis has been admitted to the long-term care facility. She has a history of falls and dementia
Which of the following interventions by the nurse will best aid in meeting an outcome goal for injury prevention? 1. The use of wrist restraints
2. Using furniture as obstacles to keep the client in the bed
3. Keeping the bed in a low position
4. Keeping a nightlight on in the room
3. Keeping the bed in a low position
Rationale:
Keeping the bed in a low position will reduce the incidence of injury should the client attempt to get up. The use of restraints could increase the incidence of injury. Using the furniture as an obstacle could cause injury if the client is able to get up. A nightlight is useful but is not the best means to prevent injury.
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Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse?
1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Have ready access to the number of a safe house for battered women.
On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.
A client repeatedly tells the nurse that "all will be well" and "I'm fine" in response to learning of a health problem that requires immediate surgery. The nurse realizes that which diagnosis is appropriate for the client at this time?
1. Compromised Family Coping 2. Ineffective Coping 3. Disabled Family Coping 4. Defensive Coping
Upholding a client's right to make a choice and to act on the choice involves
a. Affirming b. Supporting c. Informing d. Decision making