- A nurse is planning care for a client who is disoriented and at risk for falls. Assure client's safety. A nurse is planning care for a client who is disoriented and at risk for falls. b) Attach a sensor to the client that will alarm when client attempts to get up. Speaking in a loud Jun 26, 2024 · Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge teaching with the caregiver of a client who has Alzheimer's disease and has a new prescription for memantine. d. The nurse should identify that the client has which of the following types of dementia?, A Study with Quizlet and memorize flashcards containing terms like The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. , Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems? a. This helps to prioritise the client's needs and assists in setting person-centred goals. Which of the following interventions should the nurse implement to help maintain clients skin integrity? a. Sternal rub 2. Which is the greatest priority in the event of a fire? Report the fire. Report the finding to the healthcare Dec 5, 2021 · The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. Upon assessing the client on hourly rounds, the nurse determines the client's restraints pose a risk for injury to the client. place the wheelchair at a 90 degree angle B. ) The client's blood pressure is 160/78 mm Study with Quizlet and memorize flashcards containing terms like The nurses determines a client's IV solution is infusing at 250 ml/hr. Which of the following statements by the client suggests they are at risk for experiencing manifestations of a Study with Quizlet and memorize flashcards containing terms like A nurse in an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. client who has vaccinated for pneumococcus and influenza 6 months ago d. Which of the following interventions should the nurse include? Select all. 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. Apr 30, 2024 · The development and implementation of a nursing care plan tailored to the specific needs of clients with chronic confusion are essential in ensuring holistic and client-centered care. Determine the mobility status of each client . Secure the drainage bag at bladder level during transport B. Nutritional imbalance because of lack of intake Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client experiencing new onset confusion. Study with Quizlet and memorize flashcards containing terms like The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. 2. Talk the Study with Quizlet and memorize flashcards containing terms like Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?, When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as Apr 30, 2024 · The nursing care planning goals for patients with multiple sclerosis include managing symptoms such as fatigue, pain, and spasticity, promoting physical mobility and independence, preventing complications such as falls and infections, and providing emotional support and education on self-care and disease management. The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply. Which of the following findings should the nurse expect?, a nurse is caring for a client who has dementia. The nurse must provide an individual care plan to patients to deal with wandering. Place the client in a room near the nurses' station for close monitoring and quick assistance when needed. which of the following clients should the nurse expect to be at risk? (select all that apply) a. What finding should the nurse expect?, When planning care for a client with a head Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a critically ill client with autonomic dusreflexia. 3. Which should be the priority at this point? A. Encouraging both verbal and nonverbal communication d. Which test would the nurse plan on possibly omitting from the exam?, When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?, The nurse walks into a client's room and finds that the client is 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. reorient the client to self and current events, A nurse is making a home visit to a client who has AD. Apply cold compresses to the affected extremity. administer antibiotics Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client that is agitated and combative. 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. Providing immediate feedback by correcting errors in the patient's speech c. Move the bedside table away from the bedside C. -Place the client in a room near the nurses' station. , beneficence, Let the client know that, as their nurse, they are available and willing to listen. acquire the help of several people to lift the client D. 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. palpate the costovertebral angle D. Rotate assignment of daily caregivers. A patient who is older than 50 b. The health care provider is concerned the woman may have retained placental tissue. Maintain appropriate staffing to ensure the safety of all patients. According to Standard 2 of the standards of practice for mental health nurses, which of the following should the nurse expect the RN to identify as the The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. The Study with Quizlet and memorize flashcards containing terms like Which patient should the nurse identify as having the greatest risk for hypothermia? A 45-year-old A 3-day-old infant A 3-year-old A 15-year-old, The nurse is conducting a teaching session with a group of college students regarding alcohol consumption and the risk of hypothermia. What should the nurse do to avoid injuries from falls?, A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. Disrupted appearance because of weight 2. Study with Quizlet and memorize flashcards containing terms like The nurse is assessing the motor function of an unconscious client. The major nursing care plan goals for delirium are: Client will maintain agitation at a manageable level so as not to become violent. Protect the clients. ) o Permit rest periods as needed. , A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority Study with Quizlet and memorize flashcards containing terms like which finding in older adult client is associated with aging, which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer's disease, An older client with Alzheimer type dementia constantly sleeps in a semi Fowler position in bed. The client will wear the hearing aids 90% of the time. thicken all liquids c. The nurse notes that in the evenings the client becomes extremely agitated, yells, is confused, and is disoriented. Which of the following goals is appropriate for a client in this type of program?, A nurse is assessing a client in the community center. What is the most commonly assessed postanesthesia recovery emergency? 1. 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. Which client problem would the nurse select as the priority in the plan of care? 1. Pressure on the orbital rim 4. Ensure that the client is wearing nonskid slippers. Which nursing diagnosis takes the highest priority in this client's care plan? A. Move the bedside table away from the bedside. Pain because of an inflamed gastric mucosa 4. encourage daily fluid intake of 1 L C. What action can the nurse take other than the use of physical restraints? Select all that apply. Approach the client using short sentences. The following interventions should be included: Ensure that the client is wearing nonskid slippers to prevent falls by providing better traction. the client request to use the bathroom c. 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. Educate the client on the risk for falls. 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 A nurse is assisting in planning care for a client who has heart failure. 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. Use a cloth incontinence brief to contain urine and feces. Client rates pain as 7 on a scale of 0 to 10. which of the following interventions should the nurse include? ensure that the client is wearing nonskid slippers. , The charge nurse is observing a new nurse care for a patient who is at high risk for falls. The A nurse is planning care for a client who is postpartum and has thrombophlebitis. Slow the IV infusion to keep vein open rate. -Discourage the client from talking about their 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. Assess the IV insertion site for swelling. , Unintentional injuries are a major cause of disability and death in the United States. ). Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. To prevent falls in hospitalized clients , which of the following actions should the nurse take first ? Provide assistance with ambulation when indicated . Inform the client about all treatments and medications. Provide the clients on the unit 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). The client was oriented and alert when admitted. Which information should the nurse include in the -Monitor the client for the occurrence of panic attacks. c. Which of the following interventions should the nurse include? (Select all that apply) A. Allow the client to ambulate. 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 Nursing Considerations on Patients who are at Risk of Wandering. , A charge nurse in a long-term care facility is planning care for a client who has Alzheimer's disease. Dressing or grooming self-care deficit B. The nurse adds the information in the safety event report Oct 13, 2021 · The following are common nursing care planning goals and expected outcomes for risk for falls: Patient will remain free of falls. 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. , 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. 4) Offer the client the bedpan every 2 hours. Unilateral resting tremors noted in right arm. , 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 nursing interventions should the nurse include in the plan of care? A. provide a referral for nutrition counseling B. -Move the bedside table away from the bedside. place the client in a room near the nurses' station. Which of the following actions should the nurse recommend for the plan of care? Compare the client's pedal pulses bilaterally every 4 hr. Squeezing of the sternocleidomastoid muscle, he nurse is caring for the client with increased Study with Quizlet and memorize flashcards containing terms like A client is discharged to a long term care facility with an indwelling urinary catheter. o Place the client on suicide precautions. Maintain the side rails of each bed in the raised position . 6 (101. The patient is oriented to person but disoriented to place and time. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue? A. After performing hand hygiene and applying clean gloves, which of the following When planning care for a patient diagnosed with Alzheimer disease (AD), which of these interventions is most therapeutic? 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 assisting in the care of a client who has hypermagnesemia who was admitted to the medical surgical floor. Based on these observations, which is the nurse's immediate priority of care? a. Other manifestations can include needing occasional assistance with operating appliances, forgetting a name or an appointment and then remembering it later, difficulty finding the correct use of a word, and becoming tired after social activities. Clear communication can help the client feel less angry, worried, and depressed as well as increase cooperation with the implementation of care and improve the safety of the client. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has chronic pyelonephritis. monitor urinary output E. Which of the following findings should the nurse anticipate during heroin withdrawal?, A nurse is teaching a client who has an anxiety disorder about nonpharmacological ways to promote good A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client's gait belt was not in place. c) Encourage a family member to c. The client will demonstrate successful insertion of the hearing aids. keep the bed's full side rails in the up position Which actions will the nurse take? Select all that apply. client who is postop and has received A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Reduce the risk of Which topics should the nurse include in a client teaching plan? Select all that apply. - Check on the client hourly - Instruct the client in the use of 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. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. position of comfort for the nurse Study with Quizlet and memorize flashcards containing terms like Young adults should receive a dental assessment every 6 months. The client remains continent of bowel and urine. What is the priority nursing A nurse is caring for a client. 4), and SaO2 92% on room air. Maintain a quiet environment. Place the client in a room near the nurses' station. The client is disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. elevate the bed toa. the client had a CT scan of the head that indicates amyloid plaques. Client also reports nausea, vomiting, and dyspepsia. The client will verbalize an understanding of the need for hearing aids. Which of the following actions should the nurse take first? A. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? (Select all that apply. A patient who is taking antibiotics d. Which of the following interventions should the nurse include in the plan of care to treat the fever? Question: A nurse is planning care for a client who is disoriented and at risk for falls. Patient will verbalize understanding of risk factors for falls. Massage the affected extremity. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? - Bulging in the area over the surgical incision Study with Quizlet and memorize flashcards containing terms like Which term would the nurse use to document observing the characteristic gait associated with Parkinson disease?, A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Encourage increased intake of oral fluids C Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is completing a diversion program. Explanation: In planning care for a client who is disoriented and at risk for falls, the nurse should include the following interventions: A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38. The main goal is to improve Study with Quizlet and memorize flashcards containing terms like The nurse is assessing clients for postoperative complications. Which of the Study with Quizlet and memorize flashcards containing terms like A nurse is assigned to care for a hospitalized toddler. com Apr 30, 2024 · Goals and outcomes. 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 The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. Use soap and hot water to cleanse the skin. Nurses' Notes Nurses' Notes Day 1: Oriented to person, place, and time. A patient who has already fallen twice c. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a Clostridium difficile infection. The nurse should determine who is at risk of wandering. Which nursing diagnosis takes the highest priority in this client's care plan?, A client with quadriplegia is in spinal shock. Provide safety for the client and other clients on the unit. Dehydration 4. Ensure that the client is wearing nonskid slippers B. Which of the following actions should the nurse plan to take? (Select all that apply. Ensure that the client is wearing, nonskid slippers. See full list on nurseslabs. client's vital signs are w/i the expected reference range b. Contain the fire. provide protective undergarments d. Nursing Care Planning and Goals. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding, Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity, An elderly Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Which of the following interventions should the nurse include in the plan? a. Nov 11, 2021 · Planning care is essential in the delivery of appropriate nursing care. 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. For adults, where do unintentional injuries fall on the list of leading causes of A nurse on a long-term care unit is creating a plan of care for a client who has Azheimer's disease. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Study with Quizlet and memorize flashcards containing terms like The nurse is assisting a new mother with infant feeding. Measure leg circumferences. a. Client is awake, alert, and oriented x3. Which of the following interventions should the nurse plan to take to promote peristalsis? 1) Increase ambulation. Which of the following actions should the nurse take? A. Which mechanism of action would the nurse identify for this medication?, A client with Parkinsonism takes an Which information is appropriate to include in an incident report? an interpretation of the likely cause of the incident what the nurse saw and did (x) the client's statement about the incident that occurred the extenuating circumstances involved in the situation When prioritizing a client's care plan based on Maslow's hierarchy of needs, a . The nurse calls the primary health care provider to fill out and sign the safety event report. Inability to feed self because of weakness 3. The nurse should plan to use which technique to test the client's peripheral response to pain? 1. 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 The nurse is developing a plan of care for a client with new hearing aids. Study with Quizlet and memorize flashcards containing terms like The assistive personnel has bathed the client who is in restraints. lock the wheels of the bed and wheelchair C. While transferring to a chair, the client cries in pain. The Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who just died and practiced the islamic faith. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation. Patient will demonstrate a safe environment free from potential hazards. 4. 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. Following assessment of a patient's needs, the next stage is to ‘plan care’ to address the actual and potential problems that have been identified. Study with Quizlet and memorize flashcards containing terms like A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Two fingers cannot be inserted between the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an older adult client who has dementia. Which action exemplifies an accurate step of this process? A. Extinguish the fire. 2) Decrease fluid intake. Move the k N dside table away from the bedside. What action should the nurse take first? A. 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. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote patient safety and prevent injury. ) Ensure that the client is wearing nonskid slippers. Giving the patient several directions at a time to improve memory b. Findings include absent breath in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38. Based upon this information, what nursing diagnosis would be applicable to this family, A hospital client has been awakened at night by the alarm on his roommate's Jun 20, 2024 · 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. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. a nurse is planning care for a client who is disoriented and at risk for falls. the client eats all of the food provided for each of her meals d. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful. 9 degrees C (102 F). 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 A nurse is contributing to the plane of care for a client who has urinary and fecal incontinence. Which of the following interventions should the nurse include in the care plan? -Have the client wear hospital gowns during the daytime. Lung sounds 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. Determine when the IV solution was started. 6 months later: Oriented to person and place, disoriented to date and time. What should the nurse do to avoid injuries from falls? a. Gait is slow and rigid. A nurse is caring for a client experiencing new onset confusion. Which of the following instructions should the nurse include in the teaching?, A charge nurse in a long-term facility is planning care for a client who has Alzheimer's disease. Which of Study with Quizlet and memorize flashcards containing terms like The nurse cares for the client who is confused. This nursing care plan will serve as a roadmap for healthcare professionals, guiding them in delivering effective care, managing symptoms, and addressing unique c. Study with Quizlet and memorize flashcards containing terms like A child 4 years of age has a mother who is employed and works from home. Communication with the client is essential because it builds and preserves trust. Use all options. A. What assessment(s) represents a rationale for removal or adjustment ? Select all that apply. Obtain a chest x C. Which of the following information obtained by the nurse about the client indicates that the client is experiencing delirium rather than dementia? a. The nurse observes that the client is short of breath, coughing, and expectorating thick, yellow sputum. use a gait belt for ambulation b. 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. Wound infection 3. Which of the following interventions should the nurse include? (Select all that apply. Speech is slow. Which is essential for the nurse to include in the client's care plan? A) remove the restraints for 1 hour Administering a sedative at the hour of sleep B. Leaving a night-light on during the evening and night shifts C. C. In the following section, we will cover subjective and objective data related to acute confusion. 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. 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 Aug 6, 2024 · Study with Quizlet and memorize flashcards containing terms like A nurse sees smoke emerging from the suction equipment being used. A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. The client's speech pattern is rapid, and affect is belligerent. He looks confused and disoriented. Place in order the steps of the nursing process that the nurse would use for this client. 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). - Obtain a prescription to restrain the clients PRN. 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). A nurse is planning care for a client who is disoriented and at risk for falls. Povide an activity schedule that changes from day to day c. Planned care will change as a patient's needs change and as the nurse and/or other Aug 9, 2022 · 2. A The nurse should identify that making occasional errors when balancing a checkbook is an expected age-related change in an older adult. Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with transferring a client from bed to wheelchair. b. B. Which long-term goal is most appropriate for the client? 1. D. The client receives culturally appropriate care. 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. The patient has a history of increasing confusion over several years. Assigning a nursing assistant to sit with him until he falls asleep D. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist A nurse is planning care for a client who has become increasingly anxious and confused. Keep the bed's full a. client who has dysphagia b. Which is an expected outcome for this client's care? A. Which area of the clients body would the nurse Jan 26, 2024 · Nursing Diagnosis: Risk for Other-directed Violence related to suspiciousness of others secondary to acute confusion Desired Outcome: The patient will be able to prevent hurting others and use age-appropriate behaviors when interacting with others. The adult child asks 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 client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. ) - Brace all side rails on the clients bed. 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. o Encourage vigorous exercise and long walks on the unit. Plan a fall prevention program for clients at risk Jul 30, 2024 · The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. , 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. Require a family member to be in the room at all times. Nursing Interventions Study with Quizlet and memorise flashcards containing terms like The nurse is caring for a client who is hospitalized with pneumonia and is disoriented and confused 2 days after admission. Feb 11, 2021 · Risk for other-directed violence related to suspiciousness of others. Which patients would the nurse consider to be in this category? Select all that apply. Secure a restraint order from the health care provider. 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, 2. Document in the client's medical record that they have advance directives C. , A nurse is providing discharge education to a client who has hypokalemia. )-Ensure that the client is wearing nonskid slippers. Provide complete personal hygiene care for the patient. Client will not harm self or others. a nurse is monitoring a group of clients for increased risk for developing pneumonia. Nail bed pressure 3. Which of the following clinical manifestations would suggest that the client Feb 11, 2024 · A nurse is planning care for a client who is disoriented and at risk for falls. 3) Increase protein intake. What clinical manifestations would the nurse expect in this client, The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Respiratory obstruction 2. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to assess balance in an older adult client. The client sleeps through the night and stays awake most of the day. and more. Risk for injury C. Monitor the client frequently. Require the client to complete new advance directives for this admission B. o Observe and encourage food and fluid intake. Move the bedside table away from the bedside. The prescribed rate is 125 ml/hr. Disturbed sensory perception (visual) D. Assess and stabilize the client medically B. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Place the client in a room near the nurses' station. Impaired verbal A nurse is collecting data for an RN who is assessing a client who is disoriented to time and place, attempting to get out of bed without assistance, and reports left leg pain and weakness. Which critical thinking skill does the leader wants the nursing student to learn?, When donning sterile gloves, how 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. o Speaking slowly and simply. ) A. Which of the following will be most effective in preventing falls in this client? a) Complete a fall diary. ) a. client to has AIDS c. The client had A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Aug 9, 2024 · This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for injury. Which nursing action should be included in the plan of care to reduce the client's risk for infection related to the catheter? A. The client is disoriented and agitated. Ensure that copies of the client's advance directives are located in the chart a. Request a prescription for haloperidol (Haldol) 2. Limit time for the client to perform activities d. jdvoy quf pinjno yhcgk crkmv sgn uimt yuzv lmec xxbf