Nokea
A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?
- A. The client advances the cane 18 inches in front of the foot
- B. The client holds the cane in the left hand
- C. The client advances the cane and the right leg simultaneously
- D. The client holds the cane with the elbow flexed at 60°
Correct Answer: B
Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.
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A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?
- A. Give a bedtime snack
- B. Encourage a short nap in the afternoon
- C. Encourage exercise right before bed
- D. Establish a regular exercise routine 2 hours or more before bedtime
Correct Answer: D
Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
- A. Tomatoes
- B. Carrots
- C. Avocados
- D. Apricots
Correct Answer: A
Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
- A. Take the client to the dining room with 1:1 supervision
- B. Inform the client they may go to the dining room when they control their behavior
- C. Hold the meal until the client is able to come out of seclusion
- D. Serve the meal to the client in the seclusion room
Correct Answer: D
Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.
A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?
- A. How severe is your pain on a scale of 1 to 10?
- B. Where is your pain located?
- C. What medication are you taking for the pain?
- D. When did the pain start?
Correct Answer: B
Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.
A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?
- A. Increase the suction setting on the ventilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.