What questions should the practical nurse ask a family member of a 75 yr old male new admission with Mid-stage Alzheimer's to obtain the most relevant info for updating a care plan?
1. Do you have any help at home
2. Are your children worried about their father
3. What help does Mr. Robichaud re...
What questions should the practical nurse ask a family member of a 75 yr old male new admission with
Mid-stage Alzheimer's to obtain the most relevant info for updating a care plan?
1. Do you have any help at home
2. Are your children worried about their father
3. What help does Mr. Robichaud require each day
4. How frequently are you able to visit - correct answer 3. What help does Mr. Robichaud require each
day. (This information is critical in the development of a personalized care plan.)
The resident son, asks the practical nurse whether he can participate in his father's daily care when he is
available. What should the nurse do?
1. Invite the son to come and play cards with his father
2. Encourage the son to spend his days off with his father
3. Reassure the son that the fathers daily care is being provided by the health care team
4. Question son about what part of his father's care he would like to be a part of - correct answer 4.
Question son about what part of his father's care he would like to be a part of
Practical nurse witnesses resident fall to the floor. He does not appear visibly injured, but becomes
aggressive when practical nurse tries to assess him. What should the practical nurse do?
1. Reassure the resident and request assistance with a mechanical lift
2. Stay with him and ask the nurse-in-charge to contact the primary care contact
3. Wait until the resident becomes calm and complete the assessment of his injuries
4. Call for assistance, reassure the resident and provide necessary care - correct answer 4. Call for
assistance, reassure the resident and provide necessary care
Practical nurse is helping orientate a new employee, an unregulated health worker. Practical nurse
watches the UCP (unregulated care provider) helping a resident at mealtimes and notices she appears
uncomfortable. What should the nurse do?
,1. Suggest that the UCP share her concerns with other employees
2. Partner the UCP with a more experienced unregulated health worker
3. Invite the UCP to attend information sessions on Alzheimers disease
4. Ask the UCP how she feels about caring for clients with Alzheimer's disease - correct answer 4. Ask
the UCP how she feels about caring for clients with Alzheimer's disease
A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders
for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-
Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort.
While watching the pt's back during AM care the PN notices a reddened area on his sacrum. What is
proper documentation of the PN's assessment finding?
1. Small reddened area noted over sacrum
2. Reddened area over sacrum the size of a grape
3. Reddened area over sacrum 3cm in diameter, skin intact
4. Skin over sacral area appears reddened - correct answer 3. Reddened area over sacrum 3cm in
diameter, skin intact
A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders
for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-
Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort.
When administering the oral hypoglycemic pill, he states " that doesn't look like the pill I take at home."
What should the PN do?
1. Reassure the pt that this is the correct med order by the physician
2. Reassure the pt that this is the correct med although it may look different
3. Re-check the Dr's orders and the home medication history
4. RE-check the pharmacy label before giving the med - correct answer 3. Re-check the Dr's orders and
the home medication history
A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders
for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-
Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort.
,The PN is preparing to admin the pt's nitroglycerin patch. What would be the best place to apply the
patch?
1. Lower leg
2. Upper arm
3. Lumbar area
4. Upper thigh - correct answer 2. Upper arm
A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders
for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-
Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort.
The 2nd day on the medical unit, the pt develop diarrhea and begins vomiting. The Dr orders the IV rate
to increase to 150mL/h. 2 hrs later the PN notices that he is dyspneic and his RR is 32 breaths/min. The
PN auscultates his chest and notes adventitious sounds throughout. What should the PN do?
1. Discontinue the IV infusion and notify the physician
2. Reassess the IV rate and encourage deep breathing and coughing exercises
3. Maintain the IV infusion at 150mL/h and notify the physician
4. Notify the physician and anticipate a decrease in the IV rate - correct answer 4. Notify the physician
and anticipate a decrease in the IV rate
A 68 yr old in the medical unit following an MI has a history of type 2 diabetes mellitus and has orders
for IV 0.9% NaCl at 30mL/h, oxygen PRN, oral hypoglycemic daily, nitroglycerin transdermal patch (Nitro-
Dur) 0.4mg daily and nitroglycerin 0.3mg sublingual PRN for chest discomfort.
On the fourth day on the medical unit, the pt reports that he has chest discomfort and SOB. The PN
notes that he is pale, and his skin is cool and clammy . Most appropriate sequence of interventions?
1. Assess vital signs & blood glucose, then apply oxygen
2. Apply oxygen, assess vital signs and then assess blood glucose
3. Assess vital signs, apply oxygen, and then give sublingual nitroglycerin
4. Apply oxygen, assess vital signs and provide a warm blanket - correct answer 3. Assess vital signs,
apply oxygen, and then give sublingual nitroglycerin
, 13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about
recent changes in behavior and depressed mood.
Pt tells PN her stomach hurts because she is making herself vomit. Asks PN not to tell parents, how
should PN respond?
1. Tell the pt that the PN is only obliged to report vomiting if it occurs during her hospitalization
2. Remind the pt that clients have the right to determine what information is documented and reported
3. Explain to the pt that information is shared with the health care team to provide appropriate care
4. Reassure the pt that her stomach pains will subside if she stops vomiting and her condition improves -
correct answer 3. Explain to the pt that information is shared with the health care team to provide
appropriate care
13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about
recent changes in behavior and depressed mood.
In accordance with the nursing care plan, the PN sits with the pt while she eats her meals and
accompanies her to the bathroom. Today, the PN notices the females facecloths are missing from the
bathroom. What action should the PN take?
1. Discuss the issue of lost facecloths, search the room when the pt is out of her room and document
appropriately
2. Ask the pt where the facecloths are, ask her to return them and chart the missing facecloths
3. Ask the pt where the facecloths are and chart the suspicion that they are being used to hide uneaten
food
4. Discuss the issue of lost facecloths with the pt and document appropriate information - correct
answer 4. Discuss the issue of lost facecloths with the pt and document appropriate information
13 yr old female hospitalized with vomiting and generalized stomach pain. Her parents worry about
recent changes in behavior and depressed mood.
The pt is concerned about her weight. She exercise and makes food choices based on not wanting to
become fat. She says that she does not feel like eating. What should the nurse do?
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