Nokea
The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply.
- A. Ask open-ended questions
- B. Move close to the client and speak in a loud voice
- C. Remove background noise by turning off the television
- D. Touch the client on shoulder prior to speaking
- E. Use clear and simple sentences
Correct Answer: C,D,E
Rationale: Reducing background noise (C) minimizes distractions. Touching the shoulder (D) gains attention non-verbally. Using clear, simple sentences (E) accommodates cognitive impairments in Alzheimer disease.
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An 18-month old has been hospitalized six times for upper airway infections. Diagnostic studies including sweat analysis confirm the diagnosis of cystic fibrosis. Which of the following statements describes the inheritance pattern for cystic fibrosis?
- A. An affected gene is inherited from both the father and mother, who remain symptom free.
- B. Males are at risk at twice the rate as females.
- C. Autosomal recessive disorders tend to skip generations, so the children of affected parents will have children with the disorder.
- D. The disorder is transmitted by an affected gene on one of the six chromosomes.
Correct Answer: A
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring a mutated gene from both parents, who are carriers but asymptomatic.
The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?
- A. Client with blood pressure of 90/70 mm Hg and deviated trachea
- B. Client with concussion who was unconscious for 5 minutes
- C. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg
- D. Client with pain at the thoracic spine and complete paralysis of both legs
Correct Answer: A
Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.