Nokea
A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time?
- A. Avoid excess stretching of your lower extremities.
- B. Build strength by increasing the duration of daily exercise.
- C. Let me speak with your health care provider about getting a wheelchair.
- D. You should keep your feet apart and use a cane when walking.
Correct Answer: D
Rationale: A wide stance and cane improve balance. Stretching is beneficial, prolonged exercise may worsen fatigue, and a wheelchair is premature.
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The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
A client with psychotic depression is receiving Haldol (haloperidol). Which of the following side effects is associated with antipsychotic medications such as haloperidol?
- A. Akathesia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathesia , a movement disorder, is a common side effect of haloperidol. Cataracts , diaphoresis , and polyuria are not typically associated.
The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?
- A. Blood pressure
- B. Hematuria
- C. Peripheral edema
- D. Serum lipid levels
Correct Answer: A
Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.
The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
- A. The nursing assistant washes hands first thing in the morning before giving care to any client and again after all morning care is completed.
- B. The nursing assistant wears gloves during all client contact.
- C. The nursing assistant wears a gown when changing linen soiled with urine and feces.
- D. The nursing assistant changes gloves between clients but does not wash hands if gloves have been worn.
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.