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1 of 79
Term
a nurse is caring for an older adult client with delirium. which
intervention will most likely reduce the client's risk for falls?
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identify the client's needs hourly rounding by the nurse
, demonstrate how to use the call light. use of a night-light
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2 of 79
Term
a nurse is teaching about safety risks for adolescents, what should be
included?
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at this age, peer influence to
adolescents are not influenced by
participate in high-risk
their peers in making decisions
behaviors can lead to injury
teenagers are usually very cautious
ask the client to describe feelings
and avoid risky behaviors
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3 of 79
Term
a client with cystocele is encouraged to exercise to strengthen pelvic
floor muscles and prevent pelvic organ prolapse. What exercise will
,the client need to perform
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macule Kegals
(nonpalpable smaller than 1cm, ex: (reduce pelvic prolapse and
freckle) stress urinary incontinence)
i have a living will that outlines my
use mild soap and water to clean the
wishes when i am unable to make a
ear mold
decision
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4 of 79
Term
a nurse is assisting a client with his meal that is at risk for aspiration d/t
stroke, what interventions should the nurse take to prevent aspiration?
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position upright
behavioral indicators
upper back and head are
supported
(increased agitation, restlessness)
tuck chin when swallowing
, dissolve crushed tablet meds in initiate droplet precaution
sterile water
(put in private room and wear
(in 15-30mL sterile water) surgical mask within 3ft)
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5 of 79
Term
a nurse is caring for a client receiving opiates for PM, initially after PM
plan was started the client was sedated and sleeping most of the time.
after three days the client is no longer sedated and sleeping regularly.
what action should the nurse take?
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the client has a history of recurring reduce sodium intake
bowel inflammation
(stop smoking, monitor fluid intake to
(GI issues decrease motility, 2L/d, increase protein, consume small
decreasing med effectiveness, so oral frequent meals that are soft and easy
meds should be avoided) to chew)
turn on the bed alarm no action is needed at this time
maintain the bed in the lowest
position (opiates initially cause sedation
encourage the family to stay with the but it subsides with
pt maintenance pain control)
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