Which would be the most effective approach for a nurse to take when assessing the self-care needs and activities of daily living (ADLs) for an older adult?
a. Observe the level of grooming and dress that the patient demonstrates on a daily basis.
b. Interview the patient with a focus on how daily toileting and bathing are typically achieved.
c. Offer to provide the patient with the typical activities involved with bathing and grooming.
d. Interact with the patient to determine his or her ability to bathe, toilet, eat, and dress independently.
D
Interacting with the patient during ADLs (bathing, grooming, toileting, eating, dressing) presents the best opportunity to assess independence and needs related to those activities.
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A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond?
a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."
An IV is infusing at 100 gtt/min. The drop factor is 60 gtt/mL. In 24 hours, the client will have received _______________
a. 600 mL b. 1,250 mL c. 2,400 mL d. 1,440 mL
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?
A) Isosorbide mononitrate (Isordil) B) Meperidine hydrochloride (Demerol) C) Morphine sulfate (Morphine) D) Nitroglycerin transdermal patch
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response?
A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patient's LOC. C) Increase the patient's bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.