Nokea
A home health nurse is assisting a client with planning care for a family member who has Alzheimers disease. Which of the following instructions should the nurse include?
- A. Review the daily schedule with the client every morning.
- B. Limit the clients fluid intake to prevent accidents.
- C. Encourage the client to engage in complex tasks.
- D. Restrict the clients social interactions to reduce confusion.
Correct Answer: A
Rationale: The correct answer is A: Review the daily schedule with the client every morning. This instruction is important for individuals with Alzheimer's disease as it helps provide structure and routine, which can help reduce confusion and anxiety. By reviewing the daily schedule, the client can be prepared for the day's activities, promoting a sense of familiarity and independence.
Option B is incorrect because limiting fluid intake can lead to dehydration and other health issues. Option C is incorrect as individuals with Alzheimer's disease may struggle with complex tasks and may become frustrated. Option D is incorrect because social interactions are important for mental stimulation and emotional well-being, restricting them can lead to increased confusion and isolation.
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A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management. Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the clients skin?
- A. A pearly, waxy nodule
- B. A scaly, red patch
- C. A dark, irregular mole
- D. A firm, painless lump
Correct Answer: A
Rationale: The correct answer is A: A pearly, waxy nodule. Basal cell carcinoma typically presents as a pearly, waxy nodule on the skin. This characteristic appearance is due to the growth of abnormal cells in the basal cell layer of the skin. The nodule may also have small blood vessels visible on its surface. This presentation is distinct from other skin lesions. Choice B, a scaly red patch, is more indicative of conditions like psoriasis or eczema. Choice C, a dark irregular mole, is more suggestive of melanoma. Choice D, a firm, painless lump, is more characteristic of conditions like lipomas or fibromas. Thus, the correct answer is A based on the specific characteristics of basal cell carcinoma.
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, the lungs are unable to eliminate enough carbon dioxide, leading to an increase in CO2 levels in the blood, causing acidosis. This is due to inadequate ventilation or impaired gas exchange. The other options are incorrect because: B) Loss of bicarbonate is seen in metabolic acidosis, not respiratory acidosis. C) Excessive vomiting leads to metabolic alkalosis, not respiratory acidosis. D) Hyperventilation would actually correct respiratory acidosis by decreasing CO2 levels.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C, D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.