Nokea
A healthcare professional is assessing a client's extraocular eye movements. Which of the following should the professional do?
- A. Instruct the client to follow a finger through the six cardinal positions of gaze.
- B. Hold a finger 46 cm (18 in) away from the client's eyes.
- C. Ask the client to cover their right eye during assessment of the left eye.
- D. Position the client 6.1 m (20 feet) away from the Snellen chart.
Correct Answer: A
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.
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A caregiver is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the caregiver make?
- A. "Perhaps you should try to find out what is happening behind those closed doors."
- B. "Suggest that the door be left ajar for safety reasons."
- C. "At this age, children tend to become modest and value their privacy."
- D. "You should establish a disciplinary plan to stop this behavior."
Correct Answer: C
Rationale: The correct response is C: "At this age, children tend to become modest and value their privacy." During the developmental stage around 10 years old, children often start to value their privacy more and exhibit behaviors like closing doors when showering or dressing. It is a normal part of growing up and developing a sense of modesty. Choice A is incorrect as it suggests prying into the child's privacy, which may be counterproductive and invasive. Choice B is not the best response as it focuses on safety but fails to address the child's developmental stage and need for privacy. Choice D is also incorrect as it advocates for discipline without recognizing the normal developmental behavior of children at this age.
A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?
- A. Use tracheostomy covers when outdoors.
- B. Clean the tracheostomy with alcohol.
- C. Replace the tracheostomy tube every week.
- D. Cover the tracheostomy with a wet cloth when sleeping.
Correct Answer: A
Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.
The client is receiving total parenteral nutrition (TPN). Which laboratory value should the LPN/LVN monitor closely to assess for complications?
- A. Serum potassium
- B. Blood glucose
- C. Serum sodium
- D. Serum calcium
Correct Answer: B
Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the risk of hyperglycemia. TPN solutions are high in glucose, and clients may be at risk of developing hyperglycemia if the infusion rate is too high or if there are underlying issues such as insulin resistance. Monitoring serum potassium (choice A) is important but not the most crucial value to monitor in clients receiving TPN. Serum sodium (choice C) and serum calcium (choice D) are not directly impacted by TPN administration and are less likely to be affected compared to blood glucose levels.
A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original copy of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.
Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?
- A. Height in inches or centimeters.
- B. Weight in kilograms or pounds.
- C. Triceps skinfold thickness.
- D. Upper arm circumference.
Correct Answer: D
Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.