Nokea
A 93 year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
- A. Recommend the patient remain in her room at all times.
- B. Recommend family members bring pictures to the patient's room.
- C. Recommend a speech therapy consult to the doctor.
- D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct Answer: B
Rationale: Stimulation in the form of pictures may decrease signs of confusion.
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A nurse has been assigned a patient who has recently been diagnosed with Guillain-Barre' Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre' Syndrome with the patient?
- A. Guillain-Barre' Syndrome gets better after 5 years in almost all cases.
- B. Guillain-Barre' Syndrome causes limited sensation in the abdominal region.
- C. Guillain-Barre' Syndrome causes muscle weakness in the legs.
- D. Guillain-Barre' Syndrome does not affect breathing in severe cases.
Correct Answer: C
Rationale: Muscle weakness in the lower extremities is found in acute cases of Guillain-Barre' Syndrome.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: Normal saline (0.9% sodium chloride) is isotonic and safe for flushing IV lines before and after blood administration, preventing cell lysis or clotting.
A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?
- A. The children should wear long sleeves and long pants while outside.
- B. Apply insect repellant containing DEET when the children are outside.
- C. Remove standing water from the property.
- D. All of the above.
Correct Answer: D
Rationale: It is recommended that the children wear insect repellant containing DEET and long-sleeve shirts and long pants when they are outside. Removing standing water can help decrease the number of breeding mosquitoes.
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
- A. Conveying calmness with one on one interaction
- B. Recognizing and dealing with your own feelings to prevent escalation of the patient's anxiety level
- C. Encourage client participation in group therapy
- D. Listen and identify causes of their behavior
Correct Answer: C
Rationale: Acutely psychotic patients will disrupt group activities.
A client and his family facing the end stage of a terminal illness might be best served by:
- A. a rehabilitation center.
- B. an extended care facility.
- C. Hospice.
- D. a crisis intervention center.
Correct Answer: C
Rationale: Hospice has the belief that more humanized alternative care for dying clients is needed than is being provided in hospitals, which focus mostly on medical cures. No matter where the care is delivered, Hospice provides a specialized interdisciplinary team of health care professionals who work together to manage client care.