A student nurse is caring for an elderly client with dementia who ...

[CQXA]

A student nurse is caring for an elderly client with dementia who is confused and forgetful. The client is agitated, but the student leaves for a break and forgets to put the bed at the lowest level.
 
  When checking on the student's clients, the instructor discovers the student's negligence and determines that: 1. The student's work load is too difficult.
   2. The student is demonstrating appropriate safety measures.
   3. The student is demonstrating a lack of commitment to nursing.
   4. The student is appropriately taking care of self.

Question 2

The nurse assessing a child with a congenital heart defect should include which of the following when assessing the cardiac status?
 
  1. Observe for abdominal distention
   2. Inspect the chest for heaving
   3. Auscultate breath sounds
   4. Measure urine output

[vickyvicksss]

Answer to Question 1

3. The student is demonstrating a lack of commitment to nursing.

Rationale:
The student is demonstrating a lack of commitment to nursing by not providing for the safety of the client. There is no evidence that the student's load is too difficult. The student has ignored basic safety measures for this client. It is appropriate for nurses and students to take breaks; however, the safety of the client is the first commitment for the nurse.

Answer to Question 2

2. Inspect the chest for heaving

Rationale:
The nurse should inspect the client's chest for heaving, which is a lifting of the chest during contractions. Observing for abdominal distention would be done during the assessment of the client's fluid status. Auscultating breath sounds would be included in the assessment of the respiratory status. Measuring urine output is not a feature of any particular status and may or may not need to be done.

[CQXA]

Gracias!

[kswal303]

TYSM