The 80-year-old man newly admitted to a long-term care facility has suddenly become incontinent of urine at night. The nurse plans interventions to help restore self-toileting by (select all that apply):
1. waking the resident every 2 hours and escorting him to the bathroom.
2. leaving a night-light on.
3. discouraging the use of long-legged pajama bottoms.
4. placing a urinal at the bedside.
5. keeping the room uncluttered.
2, 3, 4, 5
Proving light in an uncluttered room, encouraging clothing that does not impede self-toileting, and making a urinal available increase independence and alleviate situations that make self-toileting difficult. Waking a resident not only disturbs his or her rest, but in-creases dependency on the staff.
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A client diagnosed recently with AD is prescribed donepezil (Aricept). The client's spouse inquires, "How does this work? Will this cure him?" Which is the appropriate nursing response?
1. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 2. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." 3. "This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 4. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
The home health nurse is assisting a patient and his family in planning the patient's return to work after an extensive illness. On which level of Maslow's hierarchy of basic needs does the patient's need for self-fulfillment fit?
A) Physiologic B) Safety and security C) Love and belonging D) Self-actualization
The nurse is preparing a client for coronary artery bypass surgery. What vessel does the nurse know is most commonly used for grafting?
A) Saphenous vein B) Basilic vein C) Radial artery D) Gastroepiploic artery
You note an inflamed area on the patient's skin near where an IV catheter is inserted. You should
A) report this immediately to your supervisor. B) wash the area with soap and water. C) stop the IV and ring for help. D) all of the above