Nokea
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
You may also like to solve these questions
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
Immediately following a cardiac catheterization, the client asks to go to the toilet. What is the best response by the nurse?
- A. Assist the client to the toilet
- B. Show the client where the toilet is and allow him/her to walk there if stable
- C. Assist the client to a bedside commode
- D. Assist the client onto a bedpan
Correct Answer: D
Rationale: Post-catheterization, bed rest is required to prevent bleeding at the insertion site; a bedpan maintains immobility.
The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum
- A. calcium level
- B. albumin level
- C. troponin T level
- D. potassium level
Correct Answer: A
Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (A), common in pancreatitis. Albumin (B), troponin (C), and potassium (D) are unrelated to this finding.
The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider?
- A. Cloudy outflow
- B. Low-grade fever
- C. Oliguria
- D. Pruritus
- E. Tachycardia
Correct Answer: A,B,E
Rationale: Cloudy outflow (A), fever (B), and tachycardia (E) suggest peritonitis, requiring immediate reporting. Oliguria (C) is expected in renal failure, and pruritus (D) is less urgent.