An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

Correct Answer: C

Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale: 1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior. 2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact. 3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue. 4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being. In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.

Correct Answer: C

Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.

Correct Answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.

Correct Answer: A

Rationale: The correct answer is A. Applying the fentanyl patch to a clean, dry, and hairless area of the skin ensures proper absorption and effectiveness. Moisture, oils, and hair can interfere with absorption. Option B is incorrect as heating pads can increase drug absorption and lead to overdose. Option C is incorrect because fentanyl patches are usually changed every 72 hours, not daily. Option D is incorrect because rotating application sites helps prevent skin irritation and tolerance development.

Correct Answer: B

Rationale: Correct Answer: B - Take calcium supplements with meals. Rationale: 1. Calcium is essential for bone health and helps prevent osteoporosis. 2. Taking calcium with meals enhances absorption. 3. Adequate calcium intake is crucial for individuals with osteoporosis. Summary: A: Avoiding weight-bearing exercises is incorrect as they are beneficial for bone health. C: Limiting vitamin D intake is incorrect as it is needed for calcium absorption. D: Increasing caffeine intake is incorrect as it can decrease calcium absorption and worsen osteoporosis.

Correct Answer: C

Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.

Correct Answer: C

Rationale: The correct action to prevent tracheal tissue damage in a client with a tracheostomy is to use the minimal leak technique when inflating the cuff (Choice C). This technique helps maintain proper cuff pressure, preventing excessive pressure on the tracheal tissue. Securing the tracheostomy ties firmly (Choice A) may cause pressure ulcers on the neck. Changing the tracheostomy tube daily (Choice B) is unnecessary and may introduce infection. Cleaning the stoma with hydrogen peroxide (Choice D) can be too harsh and damaging to the delicate tracheal tissue.

Correct Answer: A

Rationale: The correct answer is A: Encourage daily walking. Bradykinesia in Parkinson's disease refers to slowness of movement. Walking helps improve coordination, balance, and overall mobility in clients with Parkinson's. It promotes muscle strength and flexibility, counteracting the effects of bradykinesia. Walking also stimulates dopamine release, which is reduced in Parkinson's. Choice B is incorrect as thickened liquids are for dysphagia, not bradykinesia. Choice C is incorrect as meal frequency does not directly address bradykinesia. Choice D is incorrect as adaptive utensils help with fine motor skills, not slowness of movement.

Correct Answer: C

Rationale: The correct answer is C: Urine output of 20 ml/hour. In severe dehydration, decreased urine output indicates compromised renal function and impaired fluid balance, necessitating immediate intervention to prevent further complications. A: Heart rate of 110 bpm is elevated but not an immediate concern. B: Blood pressure of 90/60 mm Hg is low but may be compensated in dehydration. D: Dry mucous membranes are a sign of dehydration but not an immediate threat compared to inadequate urine output.