Answer to Question 1
B
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A Incorrect. The length of stay in the acute care facility is an unreliable index of stress in a resident who was relocated recently.
B Correct. To help assess the resident for stress, the nurse reviews the sequence of events that led to the relocation including if the resident had relocation options and what those options were before relocation. If the resident played an active role in the choice of facilities and had several available options, the resident is likely to experience less stress upon relocation.
C Incorrect. The presence of familiar people is an unreliable predictor of relocation stress.
D Incorrect. Touring the new facility is an unreliable predictor of relocation stress; if the tour is conducted too soon or when the resident is in pain, tired, or dis-tracted, the resident is unlikely to benefit from the tour.
Answer to Question 2
C
The resident's ability for self-care is deteriorating, and needing help with personal hygiene is an indicator of declining health because the level of activity is an indicator of an individual's health and wellness. Thus declining health is the nurse's priority in planning care. Assessing and ad-dressing medical problems, such as heart disease and nutrition, and improving sleep are among the aspects of care to restore health and well-being for which the nurse will plan. Improving sleep patterns is part of the overall plan to restore her health and wellness. A history of coronary artery disease is important information to use to plan care; however, it is part of the plan to improve the woman's overall health. Improving nutrition is part of the overall plan to restore her health and wellness.
Concept Care Map
A nurse prepares a client for anesthesia and surgery.
The surgical nurse assists the client into the correct position
The human integration pyramid care model
A health care professional taking a radial pulse and common pulse points.
Acute glaucoma