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A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
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The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?
- A. I can stop taking the medication once my symptoms improve
- B. I must eat a healthy diet and exercise regularly to reduce weight gain
- C. I should feel better within 1 week after starting this medication
- D. I will experience improved sexual performance with this medication
Correct Answer: B
Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.
The nurse is interviewing a 5-year-old client who is reporting abdominal pain. Which of the following are effective strategies for communicating with the child? Select all that apply.
- A. Allow the child to describe the symptoms
- B. Ask closed-ended questions to obtain pertinent information
- C. Explain procedures to match the child's concrete thinking
- D. Interview the child separately from the parents
- E. Maintain an eye-level position when speaking with the child
Correct Answer: A,C,E
Rationale: Allowing the child to describe symptoms encourages open communication, and interviewing separately reduces parental influence, ensuring accurate reporting. Closed-ended questions may limit a young child’s ability to express complex symptoms.
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
The nurse is caring for a client with bipolar I disorder who is experiencing an acute manic episode. Which of the following meals would be appropriate to offer the client?
- A. Baked sweet potato, kale, wheat roll, water
- B. Chicken nuggets, almonds, apple slices, milk
- C. Vegetable soup, fresh salad, dinner roll, iced tea
- D. Spaghetti with meatballs, fruit salad, sliced bread, coffee
Correct Answer: A
Rationale: A simple meal like sweet potato, kale, wheat roll, and water minimizes stimulation and is easy to eat during mania. Other meals are more complex or contain caffeine (coffee, tea), which can exacerbate symptoms.
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.