Nokea
A client suspected of having Alzheimer's disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation, the examiner names three objects. Later in the evaluation, he asks the client to name the same three objects. The examiner is testing the client's:
- A. Attention
- B. Orientation
- C. Recall
- D. Registration
Correct Answer: C
Rationale: Recalling three objects tests short-term memory (recall), a key component assessed in the Mini-Mental State Examination for Alzheimer's.
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A new graduate nurse completes her first full shift with her preceptor. It was a long, overwhelming day and the new nurse takes a deep breath and says to herself, 'You can do this! Nursing will be a challenge but you are up for it and tomorrow is a new day.' This type of communication is
- A. intrapersonal.
- B. horizontal.
- C. interpersonal.
- D. vertical.
Correct Answer: A
Rationale: Intrapersonal communication is self-talk, as the nurse reflects and motivates herself.
The nurse is assessing a client with suspected hyperthyroidism. Which of the following findings would the nurse expect?
- A. Weight gain and lethargy.
- B. Tremors and heat intolerance.
- C. Bradycardia and cool skin.
- D. Increased appetite and constipation.
Correct Answer: B
Rationale: tremors and heat intolerance are common symptoms of hyperthyroidism due to increased metabolic rate
The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:
- A. Giving the medication as ordered
- B. Providing extra water with the medication
- C. Giving the medication with an antacid
- D. Requesting an alternate form of the medication
Correct Answer: D
Rationale: Capsules can be difficult to swallow and may lodge in esophageal varices, increasing the risk of bleeding. An alternate form, such as a liquid, is safer.
A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan?
- A. The client should lie on the left side after the procedure.
- B. Cleansing enemas should be given the morning of the procedure.
- C. Blood coagulation studies might be done before the biopsy.
- D. The procedure is noninvasive and causes no pain.
Correct Answer: C
Rationale: Hepatitis C increases bleeding risk, so coagulation studies are done before a liver biopsy to ensure safety. The client lies on the right side post-procedure, enemas aren't needed, and the procedure is invasive with some pain.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.