A nurse is planning care for a client who is disoriented and at risk for falls. The nurse should determine who is at risk of wandering. Client is awake, alert, and oriented x3. Impaired verbal Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse include in the plan? Study with Quizlet and memorize flashcards containing terms like The nurse cares for the client who is confused. keep the bed's full side rails in the up position A nurse is assisting in planning care for a client who has heart failure. Which of the following actions should the nurse include to avoid the use of physical restraints? -Ensure effective pain management -Attend to the clients needs for toileting -Assign the client to a room near the nurses' station -Orient client frequently to A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38. which of the following interventions should the nurse include? ensure that the client is wearing nonskid slippers. The major nursing care plan goals for delirium are: Client will maintain agitation at a manageable level so as not to become violent. The client's speech pattern is rapid, and affect is belligerent. 3. - Check on the client hourly - Instruct the client in the use of Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with transferring a client from bed to wheelchair. " 2. Client rates pain as 7 on a scale of 0 to 10. Dressing or grooming self-care deficit B. Move the bedside table away from the bedside. Which of the following interventions should the nurse plan to take to promote peristalsis? 1) Increase ambulation. Provide complete personal hygiene care for the patient. , which characteristics are unique to vascular dementia?, the nurse is caring for a client with a brain injury who is often disoriented and agitated which interventions would the nurse include in the plan of care to decrease the risk for staff injury and more. Cardiac distress, The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 Study with Quizlet and memorize flashcards containing terms like What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type?, The leader is advising the nursing student to avoid making careless assumptions. Which client should the nurse assess first? a) A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/min b) A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on hospice care c) A client admitted one day ago with thrombophlebitis who is Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). Assess and stabilize the client medically B. Use two forms of contraception consistently, The Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an older adult client who has dementia. The client is disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Maintain appropriate staffing to ensure the safety of all patients. Dehydration 4. The nurse is assigned to care for four clients. A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which long-term goal is most appropriate for the client? 1. "If the pain increases, I must let the nurse know immediately. Ensure that the client is wearing, nonskid slippers. Allow the client to sleep for 3 to 4 hr following ECT C. " How can the nurse best address this risk? a. lock the wheels of the bed and wheelchair C. use a gait belt for ambulation b. A nurse is planning care for a client who has become increasingly anxious and confused. Use sunscreen routinely during therapy d. Which of the following interventions should the nurse include in the care plan? -Have the client wear hospital gowns during the daytime. elevate the bed toa. The A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. the client eats all of the food provided for each of her meals d. Request a prescription for haloperidol (Haldol) 2. What is the most commonly assessed postanesthesia recovery emergency? 1. , A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nursing goals and outcomes for acute confusion aim to identify and treat the underlying cause of confusion, promote safety and prevent harm, optimize patient cognition and functional status, and educate patients and families about strategies to manage acute confusion. Report the finding to the healthcare Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Study with Quizlet and memorize flashcards containing terms like The nurses determines a client's IV solution is infusing at 250 ml/hr. The nurse should record the incident in the client's medical record and fill out a Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The adult child asks Study with Quizlet and memorize flashcards containing terms like A nurse is collecting data on four clients. "Age-related cognitive changes may lead to alterations in mental status A nurse is caring for a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. Ensure that copies of the client's advance directives are located in the chart Study with Quizlet and memorize flashcards containing terms like A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Provide safety for the client and other clients on the unit. 3) Increase protein intake. Disturbed sensory perception (visual) D. administer antibiotics a. See full list on nurseslabs. The nurse should include a note on the client's chart that mentions the report. The nurse creates a nursing care plan for the child and would include which intervention in the plan? Reposition the infant frequently. Maintain a clear liquid diet for 6 to 8 hr prior to ECT B. Use a cloth incontinence brief to contain urine and feces. Which of the following interventions should the nurse implement to help maintain clients skin integrity? a. Lung sounds Which of the following interventions should the nurse include to reduce anxiety among the group members? A) Response prevention B) Guided imagery C) Aversion therapy D) Light therapy, A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which is an expected outcome for this client's care? A. Which of the following interventions should the nurse include in the plan? A. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Decrease the client's fat intake D. Provide a high-protein diet. B. ) Ensure that the client is wearing nonskid slippers. Place in order the steps of the nursing process that the nurse would use for this client. Provide the clients on the unit a nurse is planning care for a client who is disoriented and at risk for falls. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote patient safety and prevent injury. He looks confused and disoriented. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Administer IM epinephrine to the client prior to The nurse is developing a plan of care for a client with new hearing aids. Place the client in a room near the nurses' station. client's vital signs are w/i the expected reference range b. " B. The nurse should identify that the client has which of the following types of dementia?, A To prevent falls in hospitalized clients , which of the following actions should the nurse take first ? Provide assistance with ambulation when indicated . Risk for injury C. 2) Decrease fluid intake. The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. Change the client's position frequently. Determine when the IV solution was started. Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. Decrease the client's potassium intake Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to file a safety event report after a client experienced a fall. "I should have Study with Quizlet and memorize flashcards containing terms like A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Perform a mental assessment and stabilize the client Sep 2, 2023 · To prevent falls in a disoriented client, a nurse should provide clear signage in the client's environment, keep the bed in the lowest position, and use physical restraints as a last resort. Provide light massage at least daily. Which of the following actions should the nurse plan to take?, A nurse is assisting with the plan of care for a client who has a Study with Quizlet and memorize flashcards containing terms like The home care nurse is caring for an elderly client status post total hip replacement and a history of cirrhosis. Assess the IV insertion site for swelling. 9 degrees C (102 F). Assigning a nursing assistant to sit with him until he falls asleep D. Approach the client using short sentences. thicken all liquids c. encourage daily fluid intake of 1 L c. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. , The charge nurse is observing a new nurse care for a patient who is at high risk for falls. Which of the following cultural practices should the nurse expect?, A nurse is assisting with a client who has active Tb. The patient has a history of increasing confusion over several years. 4. Client also reports nausea, vomiting, and dyspepsia. Which of the following interventions should the nurse include? (Select all that apply) A. Which of the following findings should the nurse expect?, a nurse is caring for a client who has dementia. - Obtain a prescription to restrain the clients PRN. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) Diarrhea, A nurse in a rehabilitation facility has received report on four clients. The client had -Monitor the client for the occurrence of panic attacks. and more. Restrict the client's fluid intake B. The nurse must provide an individual care plan to patients to deal with wandering. Maintain the side rails of each bed in the raised position . Which critical thinking skill does the leader wants the nursing student to learn?, When donning sterile gloves, how A nurse is assisting with the plan of care for a client who has cholelithiasis. 4) Offer the client the bedpan every 2 hours. position of comfort for the nurse Study with Quizlet and memorize flashcards containing terms like The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. Which is essential for the nurse to include in the client's care plan? A) remove the restraints for 1 hour Jul 8, 2024 · Study with Quizlet and memorize flashcards containing terms like The nurse identifies a nursing diagnosis of Risk for Injury for a client who is disoriented. place the client in a room near the nurses' station. The nurse is planning the care of a client with a T1 spinal cord injury. d. The patient is oriented to person but disoriented to place and time. ) - Brace all side rails on the clients bed. which of the following interventions should the nurse include? A nurse is planning care for a client who is disoriented and at risk for falls. Respiratory obstruction 2. The provider suspects a ruptured ectopic pregnancy. The client remains continent of bowel and urine. Fluid overload Rationale: The CVP is the pressure in the vena cava, or right atrium, and is reflective of preload. Ensure that the client is wearing nonskid slippers B. Use soap and hot water to cleanse the skin. Nursing Interventions c. c. A client who has fluid Study with Quizlet and memorize flashcards containing terms like A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. A nurse is planning care for a client who is disoriented and at risk for falls. A nurse is planning care for a client who is disoriented and at risk for falls. -Discourage the client from talking about their Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is scheduled to undergo electroconvulsive treatment (ECT). Move the bedside table away from the bedside. Which of the following actions should the nurse plan to take? (Select all that apply) a. Question: A nurse is planning care for a client who is disoriented and at risk for falls. , A nurse is providing discharge education to a client who has hypokalemia. "Taking multiple medications may lead to adverse interactions or toxicity. Plan a fall prevention program for clients at risk The client is disoriented and agitated. The nurse notes that in the evenings the client becomes extremely agitated, yells, is confused, and is disoriented. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular Study with Quizlet and memorize flashcards containing terms like A client was brought to a psychiatric hospital when police found him walking around the neighborhood at night without shoes in the snow. Which should be the priority at this point? A. Allowing the patient to share a room with another elderly patient, An elderly patient who experiences nighttime confusion wanders from his room into the room of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who just died and practiced the islamic faith. The nurse should include which interventions in the plan of care? Select all that apply. After performing hand hygiene and applying clean gloves, which of the following Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client who has hypermagnesemia who was admitted to the medical surgical floor. ). Assure client's safety. provide protective undergarments d. monitor urinary output e. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. A nurse is contributing to the plane of care for a client who has urinary and fecal incontinence. Compensate for loss of depth perception. Wound infection 3. Which of the following interventions should the nurse include? (Select all that apply. The client sleeps through the night and stays awake most of the day. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. The health care provider ordered that the client have cotton wrist restraints to prevent the client from attempting to remove the intravenous (IV) and indwelling catheter. Which nursing diagnosis takes the highest priority in this client's care plan? A. Which of the following statements should the nurse make?, A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. D. Determine the mobility status of each client . Study with Quizlet and memorize flashcards containing terms like 1. reorient the client to self and current events, A nurse is making a home visit to a client who has AD. which of the following solutions should the nurse use to perform hand hygiene while caring for this client?, A nurse is preparing to remove a client's peripheral IV catheter. move the bedside table away from the bedside. Which of the following interpretations of a low CVP pressure should the nurse make? A. , Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had a fractured hip repair 2 days ago? a. Which of the following actions should the nurse take? A. What is the priority nursing a. 2. Client will not harm self or others. the client request to use the bathroom c. Nursing Care Planning and Goals. The client will verbalize an understanding of the need for hearing aids. The prescribed rate is 125 ml/hr. The client receives culturally appropriate care. Require the client to complete new advance directives for this admission B. Document in the client's medical record that they have advance directives C. A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which statement is correct regarding the filing of a safety event report? a. Leaving a night-light on during the evening and night shifts C. Do not break, crush, or chew capsules c. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist Study with Quizlet and memorize flashcards containing terms like Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain?, which assessment finding indicated that a client has had a stroke?, Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by A-fib Study with Quizlet and memorize flashcards containing terms like A nurse is assigned to care for a hospitalized toddler. A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interventions should the nurse include? Select all. Use all options. Restrict the client's calcium intake C. com Aug 9, 2024 · This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for injury. Apr 30, 2024 · Goals and outcomes. The nurse observes that the client is short of breath, coughing, and expectorating thick, yellow sputum. a nurse is planning care for a client who is disoriented and at risk for falls. A. Apply lubricating eye drops when wearing contacts b. Move the bedside table away from the bedside C. Administering a sedative at the hour of sleep B. Which of the following activities should be the highest priority for the nurse?, The goal of evidence-based practice related to restraints is to avoid the use of restraints. b. Which of the following actions should the nurse take? (Select all that apply. The client will wear the hearing aids 90% of the time. Explanation: In planning care for a client who is disoriented and at risk for falls, the nurse should include the following interventions:. , A charge nurse in a long-term care facility is planning care for a client who has Alzheimer's disease. the client had a CT scan of the head that indicates amyloid plaques. Ensure that the client is wearing nonskid slippers. Keep the bed's full Which topics should the nurse include in a client teaching plan? Select all that apply. palpate the costovertebral angle d. The client will demonstrate successful insertion of the hearing aids. Study with Quizlet and memorize flashcards containing terms like A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? a. In which order from first to last should the nurse do the following as a part of a plan to care for this client? 1. acquire the help of several people to lift the client D. which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?, a nurse in an emergency room is caring for a client who presents with manifestations that indicate Feb 11, 2021 · Risk for other-directed violence related to suspiciousness of others. place the wheelchair at a 90 degree angle B. Which of the following interventions should the nurse include? A. Which initial interventions is appropriate?, The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. What action should the nurse take first? A. The Study with Quizlet and memorize flashcards containing terms like what to teach the older adult about medication usage, What should the nurse consider when developing the plan of care for an older adult who is hospitalized for an acute illness?, When assessing an older adult, the nurse knows which of the following is a normal and physiological change related to aging? and more. Place the client in a room near the nurses' station. Which statement by the client indicates to the nurse the client understands the teaching?, A nurse is planning care for a client who has a Study with Quizlet and memorize flashcards containing terms like The nurse is using the nursing process to plan care for a client who has just been admitted to the hospital. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?, A nurse in a prenatal Nursing Considerations on Patients who are at Risk of Wandering. Which student statement indicates that learning has occurred? A. Study with Quizlet and memorize flashcards containing terms like Young adults should receive a dental assessment every 6 months. ) a. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an older adult client who is disoriented and has a history of falls. Based on these observations, which is the nurse's immediate priority of care? a. The nurse should recognize these manifestations as consistent with sundowning as demonstrated by which of the following? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a Clostridium difficile infection. Which statements by the client's spouse indicates that teaching regarding pain management has been successful? Select all that apply 1. Slow the IV infusion to keep vein open rate. , beneficence, Let the client know that, as their nurse, they are available and willing to listen. Maintain a quiet environment. Which actions will the nurse take? Select all that apply. Move the k N dside table away from the bedside. The nurse has identified the diagnosis of "risk for impaired skin integrity. Which of the following interventions should the nurse include in the plan of care to treat the fever? Study with Quizlet and memorize flashcards containing terms like a nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). the client follows directions, A nurse is planning care for four clients and is assigning task to a licensed practical nurse (LNP) and an assistive personnel (AP). C. provide a referral for nutrition counseling b. Which of Study with Quizlet and memorize flashcards containing terms like The nurse is assessing clients for postoperative complications. jlko prhoz aduqv uaz vklip vov hpg kopja xvpx xcak