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
When providing foot care, the nurse aide observes an open sore on the resident's foot. The nurse aide should
pat gently to dry and cover with a dry dressing before applying a sock.
stop the foot care immediately and ask the resident what happened.
report the skin opening to the charge nurse as soon as possible.
check the resident's sock for any wound drainage.
What is the best reason for giving frequent perineal care to residents?
It increases comfort.
It decreases sexual responses.
It helps prevent skin breakdown.
It prevents incontinence.
A resident must have assistance to walk. When leaving the resident in the residents room, what must the nurse aide do before leaving the room?
Turn on the residents television.
Make sure the residents bedpan is within reach.
Place the call light where the resident can reach it.
Say to the resident, Remember that you need help to walk.
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 resident's away from the table.
try to open the resident's mouth to check for food.
keep the resident in the chair by holding around the resident's waist.
Which of the following is the best example of using reality orientation for a resident with early dementia?
Your son plans to visit today at 2:00 p.m.
You are in the nursing home. I am here to help you.
This is your daughter Anna. Do you remember her?
Look at the time. Lunch is in 30 minutes. Are you feeling hungry?
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 resident wears a hand splint. Which observation should the nurse aide report to the nurse immediately?
The resident's fingers are cold and blue in color.
The splint was removed as scheduled in the care plan.
The resident asks to have the splint removed for a few minutes.
The resident asks the nurse aide to reposition the arm with the splint.
Which of the following best describes the daily routine needs of residents with dementia?
It is important that the resident's day be kept full of activities.
Changing daily routine is often helpful to residents with dementia.
Providing opportunities for activity and periods for rest is important.
Following a strict schedule is required to decrease confusion.
A resident whose husband died a few years ago, says, I have got to get dinner started. My husband will be home from work soon. What is the best way for the nurse aide to respond?
Offer to walk with the resident to the activity department's kitchen.
Remind the resident that the nursing home prepares her meals.
Ask the resident about her husband's favorite dinners.
Explain gently that the resident's husband is dead.
Which of the following is an observation often seen when a resident is impacted?
Liquid feces seeping out of the anus
Darkening of the resident's urine
Many soft, formed stools
Bad breath odor
When feeding a resident, the nurse aide notices that the resident keeps coughing after each drink of fluids. What is the appropriate response by the nurse aide?
Give the resident more time to swallow.
Keep the amount of fluid small by using a spoon to give fluids.
Add thickener to the fluid and see if it helps stop the coughing.
Stop the feeding and report the coughing to the charge nurse right away.
While receiving personal care in bed, a resident begins to have a seizure. The nurse aide should
hold the resident down to reduce injury.
keep the airway open and prepare to do CPR.
call the charge nurse and remain with the resident.
place a tongue blade between the resident's teeth.
The purpose of a gait or transfer belt is to
limit physical contact with ill residents who are transferred or walked.
protect the nurse aide's back when walking or transferring a resident.
help steady and support a resident when transferring or walking.
allow residents to transfer or walk independently.
A resident tells the nurse aide that she has pain down her arms and into the jaw and that she feels nauseated. The nurse aide observes that the resident appears pale and is sweating. The nurse aide should
check the resident's arms and jaw for possible injury or bruising.
check the care plan to see if the resident is on heart attack precautions.
ask if the resident might have eaten something that has upset her stomach.
recognize the seriousness of the signs and observations and report immediately.
A few minutes before the end of the shift, a resident calls and whispers to the nurse aide, I had an accident. I wet myself. What should the nurse aide do?
Explain that the next shift will assist the resident in a short time.
Remove any wet clothing and place the resident on a dry under pad.
Ask if the resident feels very uncomfortable.
Provide incontinent care to the resident.
A resident's leg has recently been amputated. Since the surgery the resident has not wanted to leave his room. What response by the nurse aide is most supportive?
You do realize that you will look normal when you get your prosthesis?
Do you think you will ever leave your room? It will help you feel better
There is no reason to feel embarrassed about losing your leg?
You used to enjoy activities. What's keeping you in your room so much?
A resident with dementia says, I need to get home. My daughters school bus is coming soon. The nurse aide knows the resident is confused because her only daughter just turned 60. What is the best response by the nurse aide?
Lets go see if Bingo has started yet. You love Bingo.
Remember you are in a nursing home. Your daughter is all grown up.
Do you mean your greatgranddaughter? Your daughter just turned 60.
What do you like to do with your daughter when she gets home from school?
When a resident is unable to stand, the residents height is generally obtained by
having coworkers hold the resident upright to allow for the measurement.
adding the length of legs, chest, and neck/head to determine the height.
asking the residents height and subtracting an inch for age-related shrinkage.
taking the measurement from head to heels while the resident is flat in bed.
Why is it important to check the feet of a resident with diabetes at least once a day?
To look for sores on the feet the resident may not feel
To check if vision problems have resulted in foot injuries
To trim the toenails so they do not become long or jagged
To make sure the resident does not get a foot fungus
A resident likes to eat breakfast in the dining room with other residents. The resident is slow when getting dressed each morning so the residents friends are often leaving when the resident gets to the dining room. The nurse aide should
set out clothing that the resident can dress in more quickly.
dress the resident to make sure the resident gets to breakfast earlier.
ask if there is any help the resident would like in the morning.
remind the resident that the friends will also be at activities later.
Which of the following describes an important requirement when providing colostomy care?
Use sterile technique when providing care.
Wear gloves for Standard Precautions.
Avoid cleansing skin near the stoma.
Position the resident on the side.
According to Standard Precautions, the nurse aide should wear gloves for which of the following procedures?
Getting linen from a linen cart
Removing soiled linen from a bed
Performing range of motion exercises
Transferring a resident to a shower chair
A nurse aide enters a room to help the resident to the bathroom. A trash can in the room is on fire. What should the nurse aide do first?
Use the residents pitcher of water to put out the fire.
Open the window to allow smoke to escape.
Remove the resident from the room.
Yell Fire! along with the location.
A resident, who is on a toileting schedule, asks to go to the bathroom frequently. The nurse aide should respond to the resident's requests by
telling the resident that it is not time.
decreasing the resident's fluid intake.
asking the resident to follow the schedule.
taking the resident to the bathroom as needed.
Sundowning is a term used to describe when residents
take short naps throughout the day.
show signs of Alzheimer's at a younger age.
prefer to go to bed earlier in the evening.
become restless and agitated late in the day.
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?
A resident has an indwelling urinary catheter. When the resident sits in a wheelchair, where should the nurse aide place the drainage bag?
On the floor directly next to the wheelchair, positioned well below the resident's bladder
Tucked at the resident's side on the seat of the chair to keep the drainage bag level with the resident's bladder
Hung from back of the wheelchair so that it is out of the resident's view and above the bladder
Attached to the seat of the wheelchair, positioned below the level of the resident's bladder
The nurse aide can help the resident have regular bowel movements by
making sure the resident gets a lot of rest.
providing a routine time for the resident to toilet.
giving the resident cereal for breakfast every morning.
keeping a bedpan within reach while the resident is in bed.
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 resident's needs?
Provide total care for the resident.
Set high standards for the resident's achievements.
Help the resident focus on even small accomplishments.
Remind the resident that she will be happier when she is home.
When weighing a resident, it is important to make sure the
resident's last measured weight is available.
scale measures both pounds and kilograms.
resident is wearing light weight clothing such as pajamas.
scale is balanced or calibrated before helping the resident onto the scale.