When the confused resident pours his cereal in a cup and drinks ...

[bcretired]

When the confused resident pours his cereal in a cup and drinks it, how should the nurse best respond?
 
  a. Put his cereal back in the bowl and hand the resident a spoon.
  b. Discard the cup with his cereal and bring fresh cereal in a bowl.
  c. Calmly instruct the resident that cereal is to be eaten from a bowl.
  d. Do nothing to interrupt the behavior.

Question 2

The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient?
 
  a. Keep the halo jacket fastened unless the patient is in a supine position.
  b. Monitor the bladder every 4 hours for signs of bladder distention.
  c. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.
  d. Assess compression stockings for proper fit.

[SamMuagrove]

Answer to Question 1

D
While this method of eating cereal is not typical, it is not harmful and allows the patient to be independent. The nurse should leave the resident alone to feed himself independently. Staff should refrain from doing what the resident can do for himself, so transferring his cereal to another container, discarding the cereal, or telling the patient that he cannot eat the cereal in a certain way is not appropriate.

Answer to Question 2

C
Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine po-sition in order to prevent sudden head movement. Bladder distention should be avoided to pre-vent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis.

[bcretired]

TYSM

[mochi09]

Excellent