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If the older adult's sons and daughters are visiting on the day of the scheduled nurse's visit, which action is most appropriate before beginning the assessment?
- A. Encourage the client's children to offer their comments at any time.
- B. Provide a private setting for conducting the assessment.
- C. Identify the names and relationships of those present.
- D. Offer to share the assessment results with the client's children.
Correct Answer: B
Rationale: A private setting ensures confidentiality and encourages honest responses, critical for an accurate health assessment.
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If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
The nurse is reviewing the medical records of children who have been abused. Which main common characteristic of parents who abuse children is the nurse most likely to identify?
- A. History of mental illness
- B. Violent behavior patterns
- C. Isolation of parent or family
- D. Parent older than 40 years of age
Correct Answer: C
Rationale: Social isolation (C) is a common trait in abusive families. Mental illness (A) affects ~10% most abusers aren’t overtly violent (B) and abuse links to younger parents (D).
If the client frequently comes to meals with the residue of soap on the face or an unbuttoned shirt, which action by the nurse is most beneficial to the client's emotional state?
- A. Send the client back to finish.
- B. Bathe and dress the client daily.
- C. Schedule the client's hygiene activities after meals.
- D. Comment on how self-reliant the client is.
Correct Answer: C
Rationale: Scheduling hygiene after meals allows assistance without embarrassment, supporting the client's dignity and emotional well-being.
Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.
The client states “I go out just about every weekend and drink pretty heavily with my friends. Does that mean I’m dependent on alcohol?” Which is the best response by the nurse?
- A. “You’re not dependent on alcohol if you never drink to the point of intoxication.”
- B. “It sounds like you feel guilty about how much you drink. Tell me more about this.”
- C. “With dependence you have a strong need to drink and feel uncomfortable if you don’t.”
- D. “You could be dependent. Consuming alcohol pretty heavily every weekend is excessive.”
Correct Answer: C
Rationale: Dependence involves a compulsive need causing distress if unmet (C). Intoxication (A) or frequency (D) don’t define it and guilt (B) is irrelevant.