Nursing Elites

1. When planning care for a client with vision loss, which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

• A. Arrange food in a consistent pattern on the client's plate
• B. Thicken liquids on the client's tray
• C. Provide small-handled utensils for the client
• D. Assign a staff member to feed the client

Correct answer: A

Rationale: When a client has vision loss, arranging food in a consistent pattern on the plate can help them locate and identify different food items more easily. This intervention promotes independence and allows the client to feed themselves with greater ease. Thicking liquids on the tray, providing small-handled utensils, or assigning a staff member to feed the client may not directly address the client's need for assistance with feeding due to vision loss. Thicking liquids is more related to swallowing difficulties, providing small-handled utensils can be helpful for clients with limited dexterity, and assigning a staff member to feed the client may not promote independence.

2. Which action by a patient indicates that the home health nurse�s teaching about glargine and regular insulin has been successful?

• A. The patient administers the glargine 30 minutes before each meal
• B. The patient�s family prefills the syringes with the mix of insulins weekly.
• C. The patient draws up the regular insulin and then the glargine in the same syringe.
• D. The patient disposes of the open vials of glargine and regular insulin after 4 weeks

Correct answer: D

Rationale:

3. In order to minimize or avoid negative outcomes as a result of the violation and disciplinary action, the employee should offer which of the following?

• A. Excuses
• B. Discipline
• C. Suggestions
• D. Rules

Correct answer: C

Rationale: In order to minimize or avoid negative outcomes resulting from a violation and disciplinary action, the employee should offer suggestions. By providing suggestions, the employee demonstrates a willingness to improve and prevent future occurrences. Offering excuses (choice A) may deflect responsibility and not address the issue at hand. Discipline (choice B) is the action taken by the employer, not the employee. Rules (choice D) are guidelines to follow, but in this context, offering suggestions for improvement is more relevant.

4. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the healthcare provider?

• A. Hemoglobin A1C level is 7.9%.
• B. Last eye exam was 18 months ago.
• C. Glomerular filtration rate is decreased.
• D. Patient has questions about the prescribed diet.

Correct answer: C

Rationale: The most important finding to discuss with the healthcare provider is the decreased glomerular filtration rate. In patients on metformin therapy, monitoring kidney function is crucial as metformin is primarily excreted through the kidneys. A decreased glomerular filtration rate can lead to metformin accumulation in the body, increasing the risk of lactic acidosis, a serious adverse effect. The hemoglobin A1C level being 7.9% indicates poor diabetes control but can be addressed through medication adjustments and lifestyle modifications. The patient needing an eye exam after 18 months is important but not as urgent as discussing the decreased glomerular filtration rate. Patient questions about the prescribed diet can be addressed during the visit without the need for immediate healthcare provider intervention.

5. What behaviors can be observed before a person becomes violent? (EXCEPT)

• A. Wandering
• B. Tense shoulders and clenched fists
• C. Blank stare
• D. Positioned with one foot in back and an arm pulled back

Correct answer: A

Rationale: Before a person becomes violent, observable behaviors may include tense shoulders, clenched fists, a blank stare, and being positioned with one foot in back and an arm pulled back. Wandering is not typically associated with threatening behaviors signaling imminent violence. DelBel (2003) suggests that strategies such as relaxed body language, maintaining physical distance, and silence can help de-escalate an agitated individual's response.

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