Nokea
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead w/the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.
Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.
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A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.
- A. Older adults are more prone to dehydration than younger adults.
- B. Older adults need the same amount of most vitamins and minerals as younger adults.
- C. Many older men and women need calcium supplementation.
- D. Older adults need more calories than they did when they were younger.
- E. Older adults should consume a diet low in carbohydrates.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?
- A. A word she whispers 30cm from his ear
- B. A number she traces on the palm of his hand
- C. The vibration of a tuning fork she places on his foot
- D. A familiar object she places in his hand
Correct Answer: D
Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
- A. Warm the enema prior to instillation
- B. Position the client on the left side with the right leg flexed forward
- C. Lubricate the rectal tube or nozzle
- D. Slowly insert the rectal tube about 2 inches
- E. Hang the enema container 24 inches above the client's anus
Correct Answer: A, B, C
Rationale: The correct steps for administering a cleansing enema are to warm the enema prior to instillation to prevent discomfort, position the client on the left side with the right leg flexed forward to facilitate the flow of the solution, and lubricate the rectal tube or nozzle to ease insertion. Warming the enema helps relax the colon, the left side position helps the solution flow toward the rectum, and lubrication minimizes discomfort and potential injury. Other choices are incorrect: slowly inserting the rectal tube 2 inches is too shallow, hanging the enema container 24 inches above the client's anus may be too high causing a rapid flow and potential injury.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. AP
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from the PACU following thoracic surgery due to their advanced training and skill set. RNs are qualified to assess, monitor, and manage complex post-operative care needs, including respiratory status, pain management, and hemodynamic stability. Charge nurses may have administrative duties and may not be available to provide direct patient care. LPNs have a more limited scope of practice and may not have the necessary skills to care for a post-thoracic surgery patient. Advanced practice nurses (AP) typically have specialized roles and responsibilities that may not align with providing direct care in this situation.
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.