Nokea
A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
- A. Placing mirrors in several locations in the home
- B. Placing a picture of herself in her bedroom
- C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on
- D. Alternating healthcare workers to prevent boredom
Correct Answer: C
Rationale: Simple signs help orient clients with Alzheimer's, reducing confusion and promoting independence in a new environment.
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Which action is contraindicated in the client with epiglottis?
- A. Ambulation
- B. Oral airway assessment using a tongue blade
- C. Placing a blood pressure cuff on the arm
- D. Checking the deep tendon reflexes.
Correct Answer: B
Rationale: Using a tongue blade can trigger airway obstruction in epiglottitis, making it contraindicated.
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
- A. A family history of laryngeal cancer
- B. Chronic inhalation of noxious fumes
- C. Frequent straining of the vocal cords
- D. A history of frequent alcohol and tobacco use
Correct Answer: D
Rationale: Frequent alcohol and tobacco use is the most significant risk factor for laryngeal cancer due to chronic irritation and carcinogenic effects on laryngeal tissues.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) is characterized by logical and coherent thought processes, enabling problem-solving with concrete objects.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria is a classic sign of right-sided heart failure due to fluid redistribution when lying down.
The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
- A. Providing supplemental oxygen by a ventilated mask
- B. Performing auscultation of the abdomen for the presence of active bowel sounds
- C. Inserting a nasogastric tube to check for esophageal patency
- D. Positioning on the left side with head and chest elevated
Correct Answer: A
Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.