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A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
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Which of the following statement is NOT true about cultural competence?
- A. Respects client's beliefs
- B. Improves quality of care
- C. Requires the nurse to impose her beliefs
- D. Enhances communication
Correct Answer: C
Rationale: Cultural competence respects beliefs (A), improves care (B), enhances communication (D) 'impose her beliefs' (C) isn't true, as it contradicts respecting client culture, per standards. C's imposition opposes competence's goal of sensitivity, making it the untrue statement.
Which of the following statement best describe spiritual care in nursing?
- A. Ignoring beliefs
- B. Supporting spiritual needs
- C. A medical fix
- D. A one-time talk
Correct Answer: B
Rationale: Spiritual care is supporting spiritual needs (B), per nursing e.g., prayer support. Not ignoring (A), not medical (C), not one-time (D) holistic focus. B best defines its role, enhancing Mr. Gary's well-being, making it correct.
A nurse working in a community health center is focusing on illness prevention for a group of young adults. Which action reflects primary prevention?
- A. Screening for sexually transmitted infections
- B. Educating about the risks of smoking
- C. Referring clients with depression to a counselor
- D. Planning care for clients with asthma
Correct Answer: B
Rationale: Primary prevention targets illness before it strikes, ideal for young adults shaping lifelong habits. Educating about smoking risks cancer, lung damage aims to deter uptake or prompt quitting, a modifiable behavior with huge impact, as smoking's a top preventable death cause. Screening for STIs is secondary, catching disease early, not stopping it. Referring depression cases or planning asthma care is tertiary, managing conditions, not preventing onset. Smoking education fits primary prevention's proactive core studies show early awareness cuts initiation rates perfect for a community setting where young adults face peer pressures. Nursing uses this to shift trajectories, reducing chronic illness odds through informed choice, a powerful, scalable action for this age group's health future.
The nurse is providing dietary instruction for a client with hypoglycemia. To prevent hypoglycemic reactions, the nurse should instruct the client to:
- A. Eat a candy bar if he feels lightheaded
- B. Always carry a quick source of sugar
- C. Limit his intake of fluids with meals
- D. Avoid eating large meals
Correct Answer: B
Rationale: Carrying a quick sugar source (e.g., glucose tabs) prevents hypoglycemic reactions by rapidly raising blood sugar candy is less precise, fluid limits are unrelated, and large meals don't directly cause drops. Nurses teach this, ensuring safety, critical for hypoglycemia management.
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.