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A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.
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A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct findings for a client with Bell's palsy are muscle distortion, pain behind the ear, and impaired taste. Muscle distortion occurs due to facial nerve paralysis, leading to drooping or weakness on one side of the face. Pain behind the ear can result from inflammation of the facial nerve. Impaired taste can occur due to dysfunction of the taste buds innervated by the facial nerve. Hearing loss (C) is not typically associated with Bell's palsy. Facial twitching (D) may occur in other conditions like hemifacial spasm but not a defining feature of Bell's palsy.
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, “Go away! No one can help me.†Which of the following responses should the nurse make?
- A. Everything will be ok.
- B. I will come back later and we can talk.
- C. Why are you crying?
- D. Do you think crying will help?
Correct Answer: B
Rationale: The correct answer is B: "I will come back later and we can talk." This response shows empathy, respect for the client's autonomy, and a willingness to provide support without being intrusive. By offering to come back later, the nurse acknowledges the client's feelings and demonstrates a willingness to engage in a supportive conversation when the client is ready.
Choice A is incorrect because it dismisses the client's feelings without offering meaningful support. Choice C may come off as confrontational and put the client on the defensive. Choice D is dismissive and lacks empathy, potentially making the client feel unsupported. Overall, choice B is the best response as it respects the client's feelings and allows for a supportive conversation at a later time.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.