The nurse assesses a resident who was transferred yesterday from an acute care hospital. Which ...

Answer to #1

B

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A Incorrect. The length of stay in the acute care facility is an unreliable index of stress in a resident who was relocated recently.
B Correct. To help assess the resident for stress, the nurse reviews the sequence of events that led to the relocation including if the resident had relocation options and what those options were before relocation. If the resident played an active role in the choice of facilities and had several available options, the resident is likely to experience less stress upon relocation.
C Incorrect. The presence of familiar people is an unreliable predictor of relocation stress.
D Incorrect. Touring the new facility is an unreliable predictor of relocation stress; if the tour is conducted too soon or when the resident is in pain, tired, or dis-tracted, the resident is unlikely to benefit from the tour.

Answer to #2

C
The resident's ability for self-care is deteriorating, and needing help with personal hygiene is an indicator of declining health because the level of activity is an indicator of an individual's health and wellness. Thus declining health is the nurse's priority in planning care. Assessing and ad-dressing medical problems, such as heart disease and nutrition, and improving sleep are among the aspects of care to restore health and well-being for which the nurse will plan. Improving sleep patterns is part of the overall plan to restore her health and wellness. A history of coronary artery disease is important information to use to plan care; however, it is part of the plan to improve the woman's overall health. Improving nutrition is part of the overall plan to restore her health and wellness.

Answer to #3

B

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A Incorrect. Asking about shivering can be ineffective with an older adult who is confused and disoriented because the response can be incorrect. However, to display respect, the nurse should ask the question.
B Correct. Older adults are at higher risk of hypothermia in the community because hypothermia is difficult to detect and because, as hypothermia sets in, the older adult can respond to a lower temperature. This man has clinical indicators of hypothermia, so the home care nurse assesses the ambient temperature first for a baseline determination because the household temperature should have the most profound impact on his body temperature.
C Incorrect. The type of food preparation can offer additional clues about the older adult's hypothermia and mental status because, if he is eating cold foods like sandwiches and yogurt, he can be contributing to the problem unwittingly.
D Incorrect. The nurse assesses the older adult who is disoriented and confused for injury as a likely cause of a change in mental status. However, because the older adult was not confused and was oriented in the hospital, the nurse looks for clinical indicators for environmental factors.

Answer to #4

D

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A Incorrect. The receiving nurse incorporates patient goals into the plan.
B Incorrect. The sending nurse ensures that the patient is stable for the transfer to prevent decompensation during the trip or shortly after arrival at the new facili-ty.
C Incorrect. The sending nurse is responsible for providing clear, comprehensive, and complete patient documentation.
D Correct. A shared responsibility of the sending and the receiving nurses or care team is to regard the transition as a transfer versus a discharge and to provide continuous and consistent nursing care throughout the transfer phase. To ac-complish this, the two nurses or groups must have clear, comprehensive com-munication.

Answer to #5

B
Polypharmacy contributes to sleep problems as a result of medication side effects and drug inte-ractions. Decreased exposure to sunlight contributes to sleep problems. Sleep aids may assist with sleep issues. Decreased fluid intake may lead to dehydration, which may result in lethargy.

Answer to #6

D

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A Incorrect. This is a reasonable approach to communicating the risk of falls, but it cannot take the place of instructing the patient directly about prevention.
B Incorrect. Needs of an older adult can contribute to the risk of falls as an indi-vidual leans and reaches for something; thus, call bell instructions are a reason-able approach for preventing falls. However, before providing the call bell in-structions, the nurse needed to tell him to call for help.
C Incorrect. A urinal for a man and drinking water are common items older adults need, but reaching for them can contribute to falls.
D Correct. The nurse accomplished the most important aspect of fall prevention with the assessment, but in an attempt to communicate the fall risk to other staff members, the nurse failed to communicate properly to the patient about fall prevention before leaving the room.

Thank you Jesus, my teacher is bad at explaining

Praise the LORD ha ha No worries