Nokea
A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is
- A. Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK.'
- B. The food has been prepared in our kitchen and is not poisoned.'
- C. Let's see if your partner could bring food from home.'
- D. If you don't eat, I will have to suggest for you to be tube fed.'
Correct Answer: C
Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.
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An 18-month-old child has been placed in Bryant's traction. The nurse knows that the traction is properly applied when:
- A. the affected leg is extended and attached to traction at the foot of the bed.
- B. the legs are at right angles to the child's body and the buttocks are two inches off the bed.
- C. the legs are at right angles to the child's body and the nurse can just put his/her fingers underneath the child's buttocks.
- D. the affected leg is extended and attached to traction at the foot of the bed and there is a vertical pull at the popliteal area.
Correct Answer: C
Rationale: Bryant's traction for infants involves both legs at 90 degrees to the body, with buttocks slightly off the bed (fingers can fit underneath), ensuring proper alignment and traction force.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.
A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
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.
The nurse is providing care in the home to a person who has AIDS. Which behavior, if observed by the nurse, indicates a need for further instruction?
- A. The client uses the same dishes as the rest of the family.
- B. The client shares a bathroom with the rest of the family.
- C. The client and his brother use the same razor.
- D. The client often cooks for the family.
Correct Answer: C
Rationale: Sharing razors risks bloodborne HIV transmission, requiring education. Using shared dishes, bathrooms, or cooking poses no significant risk with standard precautions.