Nokea
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
- A. Allowing the client to perform activities of daily living as much as possible unassisted
- B. Confronting confabulations
- C. Reality testing
- D. Providing a highly stimulating environment
Correct Answer: A
Rationale: This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. This answer is incorrect. Confrontation tends to increase anxiety. This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. This answer is incorrect. A highly stimulating environment increases distractibility and anxiety.
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The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head of the bed
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?
- A. Standard precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
- A. Complete blood count
- B. Clean-catch urinalysis
- C. Liver profile
- D. Thyroid function test
Correct Answer: C
Rationale: Isotretinoin can cause liver toxicity, requiring a baseline liver profile to monitor for elevations in liver enzymes. CBC, urinalysis, and thyroid tests are not primary concerns.
An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?
- A. The client is asymptomatic.
- B. The urine is free of bacteria.
- C. The urine contains blood.
- D. Males are affected more often.
Correct Answer: B
Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms without bacterial infection, so the urine is typically free of bacteria, unlike bacterial cystitis.
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.