Nokea
A 70-year-old, previously well client asks the nurse, 'I notice I have tremors. Is this just normal for my age?' The best response for the nurse to make is which of the following?
- A. I wouldn't be worried because this is common with aging
- B. You should report this to the physician because it may indicate a problem
- C. You should drink orange juice when this occurs
- D. You should have your blood pressure checked when this occurs
Correct Answer: B
Rationale: Tremors in a 70-year-old are not necessarily normal and may indicate conditions like Parkinson's or medication side effects, requiring physician evaluation. Orange juice or blood pressure checks are not directly relevant.
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A client with a history of schizophrenia is admitted with auditory hallucinations. The nurse should prioritize which of the following interventions?
- A. Provide a quiet environment.
- B. Administer haloperidol as prescribed.
- C. Encourage group therapy immediately.
- D. Restrict the client to their room.
Correct Answer: A, B
Rationale: A quiet environment and haloperidol reduce stimulation and manage hallucinations.
The nurse is admitting a client with a diagnosis of Guillain-Barre syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem?
- A. Meningitis
- B. Seizures or head trauma
- C. A back injury or spinal cord trauma
- D. A respiratory or gastrointestinal (GI) infection
Correct Answer: D
Rationale: Guillain-Barre syndrome is a clinical condition of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally it has been triggered by vaccination or surgery. The other options are not associated with an incidence of this syndrome.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.
After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.
Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
- A. Deficient fluid volume
- B. Impaired skin integrity
- C. Acute pain
- D. Impaired gas exchange
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.