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1.A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take?
ANS: Escort the client to a quiet area on the nursing unit.
-A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands.
2.A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination?
ANS: Use intermittent urinary catheterization for the client at regular intervals.
-A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.
3.A nurse is assisting with an education program about car restraint safety for a group of parents. Which statement by the parent indicates an understanding of the instructions?
ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
-When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash.
4.A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which instructions should the nurse include in the teaching?
ANS: Drink high-protein and high-calorie nutritional supplements.
-The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the client’s muscle mass.
5.When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE is removed first?
ANS: Gloves
-The greatest risk is contamination from pathogens that might be present on the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated.
6.A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP? ANS: Generalized Petechiae
-Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the

neck. However, petechiae all over the newborn’s body can indicate infection or decreased platelet count and should be reported to the provider.

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Subjects of Health Assessment - Chamberlain College Of Nursing

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