A resident is restrained. What observation should the nurse aide report to the nurse immediately?
The resident states, I do not like this thing.
The residents position needs to be adjusted.
The resident has suddenly become very agitated.
The restraint was removed according to the care plan schedule.
Correct Answer :
C. The resident has suddenly become very agitated.
Related Questions
Which of the following describes a residents concern that needs to be reported to the charge nurse immediately?
A residents complaint of not getting to activities on time.
A resident who states a need for a new pair of elastic stockings.
A resident with dementia who states the need to talk to the residents son.
A resident who has always been oriented is suddenly scared and confused.
Which of the following is considered a normal age-related change seen in elderly residents?
Increase in appetite
Decrease in constipation
Decrease in taste sensation and smell
Increase in amount of confusion experienced daily
A nurse aide is assigned to a table in the dining room during the residents lunch. One of the residents who is seated at the table begins to have a seizure. The nurse has been called. The next action by the nurse aide should be to
guide the resident from the chair to the floor.
remove the other residents away from the table.
try to open the residents mouth to check for food.
keep the resident in the chair by holding around the residents waist.
A resident with advance directives has a DNR order. This means that the resident
does not remember.
should not be restrained.
does not respond to instructions.
should not be resuscitated.
A nurse aide enters a room just as a residents wife slaps the resident. The resident does not seem upset or hurt. What should the nurse aide do?
Leave the room and close the door to allow privacy.
Consider if this is normal behavior for this couple.
Report the observation to the charge nurse immediately.
Tell the wife that she must leave the facility for the day.
When counting a residents pulse, the nurse aide should
notice if the rhythm of the heart-beat is regular.
ask if the resident takes any heart medication.
consider the time of day when the pulse is taken.
multiply the rate by four if counted for 30 seconds.
A resident is NPO because of nausea. What should the nurse aide do?
Give the resident fluids in small amounts.
Provide the resident with a small cup of ice chips.
Ask if the resident can handle any fluids with the nausea.
Remove any fluids at the bedside including the water pitcher.
Which of the following is an observation often seen when a resident is impacted?
Liquid feces seeping out of the anus
Darkening of the residents urine
Many soft, formed stools
Bad breath odor
A resident tells the nurse aide about being bored. The resident says, My days seem to last forever. What should the nurse aide do?
Tell the resident, I know what you mean. My days seem long too.
Ask the charge nurse if the resident can have some medication.
Ask about activities the resident has enjoyed in the past.
Tell the resident to check the activity schedule.
When preparing to shower a resident, what should the nurse aide do next after checking the water temperature?
Give the resident a washcloth to hold
Suggest the resident wash his or her face
Ask the resident to check the water temperature
Check if the resident wants a partial or full shower
Which of the following is most important to closely observe when a resident wears elastic stockings, the type that are worn to help circulation?
The residents shoe-fit
The residents pulse rate
The way the resident walks
The color of the residents toes
The resident is on a toileting schedule for bladder retraining. Which of the following is the best response by the nurse aide when it is time to toilet the resident?
Have you been able to hold it since you last went to the toilet?
How much longer do you feel like you can hold it?
May I please check to see if you are wet?
Can I help you to the bathroom now?
Which of the following actions helps to prevent skin tears?
Keeping side rails raised
Using less lotion on the skin
Sliding the resident up in the bed
Dressing the resident in long sleeves
While feeding a resident, the nurse aide notices that the resident is coughing a lot after each drink of fluid. What is the appropriate response by the nurse aide?
Allow the resident more time to swallow.
Use a straw when giving the resident fluids.
Add a thickening product to the residents fluids.
Stop feeding and ask a nurse to check the resident.
The nurse aide is to obtain a residents weight. The nurse aide should
ask if the resident remembers his/her last weight.
ask when the resident last ate food or drank fluid.
wait until after the resident has a bowel movement.
check what scale is usually used for this resident.
A resident with a feeding tube is scheduled for a shower. The residents feeding tube is connected to a pump. Which of the following is the appropriate response by the nurse aide?
Disconnect the feeding tube temporarily to give the shower.
Protect the pump with a plastic bag before bringing into the shower room.
Ask the charge nurse for assistance with the feeding pump.
Give the resident a bed bath since the resident has a feeding tube.
A residents hands shake when trying to drink liquids, causing the liquids to spill. What is the best response by the nurse aide?
Thicken the liquid so it will not spill.
Place a clothing protector on the resident.
Seat the resident with other residents who also spill.
Suggest that the resident might do well with a cup with a lid.
Which of the following should be reported to the charge nurse immediately?
A residents change in appetite
A residents complaint of chest pain
A resident who refuses to take a scheduled tub bath
A resident who wanders is found napping in another residents bed
A nurse aide is giving a resident a bed bath. Which of the following should the nurse aide do during the bed bath?
Keep the bed in the lowest position throughout bathing.
Keep the residents body covered during the bath.
Open the window for fresh air during the bath.
Add a lot of soap to the water in the basin.
Why should residents who are unable to change their own positions, have their positions changed by staff at least every two hours?
Correct residents posture
Improve the residents breathing
Promote circulation at pressure points
Provide an opportunity for incontinent care
A resident says she is 5 feet 6 inches tall. When the nurse aide measures the residents height, the resident is 5 feet 4 inches. What should the nurse aide do?
Record the residents height as 5 feet 4 inches.
Record the residents height as 5 feet 6 inches.
Explain that older people shrink with aging.
Measure the resident again.
When going to take routine vital signs, the nurse aide discovers that a minister is praying with the resident. The nurse aide should
ask how long the minister plans to visit.
explain politely that it is time to take vital signs.
check if the resident is praying before interrupting.
wait to take the vital signs after the minister has left.
A resident is admitted to the nursing home for rehabilitation after a stroke. The plan is for the resident to stay only a short time, before returning home. Which of the following shows the best support of the residents needs?
Provide total care for the resident.
Set high standards for the residents achievements.
Help the resident focus on even small accomplishments.
Remind the resident that she will be happier when she is home.
A resident with an indwelling catheter says, I need to urinate. Which of the following is the best response by the nurse aide?
Check to see if the tubing is kinked and draining properly.
Report to the charge nurse that the resident is very confused.
Remind the resident this is impossible since a catheter is in place.
Tell the resident to try to urinate since the urine will collect in the bag.
How much assistance does a resident receiving PROM need from the nurse aide?
Partial assistance with range of motion exercises
Full assistance with the nurse aide taking the joints through exercises
Minimal assistance to just remind the resident when it is time to exercise.
Minimal assistance to provide extremity support while the resident moves joints
Which foods are found on a high protein diet?
Pasta and rice
Meat and eggs
Fruits and vegetables
Whole grains and milk products
When bathing a resident, the nurse aide observes that the residents great toe is red and swollen. Which of the following is the appropriate action by the nurse aide?
Protect the toe by putting on an extra sock.
Report the observation to the charge nurse.
Apply an antibiotic ointment to prevent infection.
Soak the foot in very warm water and dry gently.
The first step the nurse aide should take when discovering a fire is to
check how quickly the fire is spreading.
remove any residents near the fire.
throw a blanket over the flames.
pull the alarm.
A resident reports that his wrist watch is missing. The nurse aide should ask
if the resident thinks someone took it.
if the resident has checked the lost and found box.
who was assigned to the resident on the previous shift.
for permission to help look around the residents room.
What is the main purpose of a restorative care program?
Ensure the resident can return home
Provide meaningful activities for the resident
Help the resident improve his/her level of functioning
Provide assistance with activities of daily living (ADLs)