Nokea
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- A. Serve high-calorie foods she can carry with her
- B. Encourage her appetite by sending out for her favorite foods
- C. Serve her small, attractively arranged portions
- D. Allow her in the unit kitchen for extra food whenever she pleases
Correct Answer: A
Rationale: High-calorie, portable foods accommodate the restlessness and distractibility of mania, ensuring adequate nutrition.
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The nurse is caring for an elderly female client in an extended care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate?
- A. provide written materials to explain medications
- B. stand in front of the client when addressing her
- C. limit room lighting to create a relaxed environment
- D. encourage use of radio and CDs
Correct Answer: B
Rationale: Standing in front of the client maximizes her ability to see the nurse, as dry AMD affects central vision, making clear visual communication essential.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Myasthenia gravis is characterized by muscle weakness that worsens with activity and improves with rest, typically more pronounced at the end of the day.
A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.
All of the following are common symptoms seen in clients diagnosed with tuberculosis (TB) EXCEPT
- A. nail clubbing.
- B. night sweats.
- C. weight gain.
- D. fever.
Correct Answer: C
Rationale: TB symptoms include night sweats, fever, and weight loss. Weight gain is not typical, and nail clubbing is more associated with chronic lung conditions like COPD.
For which of the following reasons would the nurse use the Braden Scale to assess a client?
- A. To determine if the client is suffering from delirium.
- B. To determine if the client is at risk for developing pressure sores.
- C. To determine if the client is at risk for falls.
- D. To determine if the client is at risk for substance abuse.
Correct Answer: B
Rationale: The Braden Scale assesses risk for pressure sores (B) by evaluating factors like mobility and skin moisture. It is not used for delirium (A), falls (C), or substance abuse (D).