Nokea
A client with a history of multiple sclerosis is admitted with muscle weakness. The nurse should include which of the following in the plan of care?
- A. Assist with activities of daily living.
- B. Restrict physical activity.
- C. Provide a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Assisting with activities of daily living supports safety and independence in multiple sclerosis.
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A client with a fracture is placed in skeletal traction. What is the nurse's priority assessment?
- A. Skin integrity at pin sites.
- B. Range of motion in the affected limb.
- C. Pain level during movement.
- D. Muscle strength in the unaffected limb.
Correct Answer: A
Rationale: Monitoring skin integrity at pin sites is critical to detect infection or tissue breakdown in skeletal traction.
A client diagnosed with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action should the nurse take when planning a bed assignment?
- A. Place the client in a private, well-ventilated room.
- B. Plan to transfer the client to the intensive care unit.
- C. Reserve the bed furthest away from the door in a double room.
- D. Assign the client to share a double room with a noninfectious client.
Correct Answer: A
Rationale: According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well ventilated and should have at least 6 to 12 exchanges of fresh air per hour and should be ventilated to the outside if possible. Therefore, option 1 is the only correct choice.
Which of the following is most closely aligned with the principles and concepts of informed consent?
- A. Justice
- B. Fidelity
- C. Self determination
- D. Nonmalficence
Correct Answer: C
Rationale: Informed consent is most closely aligned with self-determination , as it empowers clients to make autonomous decisions about their care based on full disclosure of information.
A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?
- A. When I injure my toe, I will plan to put iodine on it.'
- B. I should inspect my feet at least once a week.'
- C. It is okay to go barefoot in the house.'
- D. It is important to dry my feet carefully after my bath.'
Correct Answer: D
Rationale: Thorough drying prevents moisture-related infections, critical for diabetic foot care to avoid complications like ulcers.
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. The nurse monitors the client for relief of which symptom?
- A. Flatus
- B. Heartburn
- C. Rectal pain
- D. Muscle twitching
Correct Answer: B
Rationale: Calcium carbonate is used as an antacid for the relief of heartburn and indigestion. It can also be used as a calcium supplement or to bind phosphorus in the gastrointestinal tract in clients with renal failure. The remaining options are unrelated to this medication.