Nokea
A man who had a cerebrovascular accident has expressive aphasia. Which approach will help communication the most?
- A. The nurse should write to the client and the client should write back.
- B. The nurse should anticipate the client's needs as much as possible.
- C. The nurse should encourage the client to speak as much as possible.
- D. A family member should stay with the client and express the client's needs to the nurse.
Correct Answer: C
Rationale: Encouraging speech practice aids communication recovery in expressive aphasia, fostering independence. Writing, anticipating needs, or relying on family are less effective.
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The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
- A. Explain to him that no one is poisoning his food
- B. Tell him that the food is prepared in the hospital under secure conditions
- C. Taste his food to assure him that it is not being poisoned
- D. Offer him food that is in individual containers
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any eye pain.
- C. Use the drops every 4 hours.
- D. Avoid regular eye exams.
Correct Answer: B
Rationale: Eye pain may indicate a complication with latanoprost, requiring reporting. Options A, C, and D are incorrect.
A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
- A. Supportive and helpful to the victim.
- B. Disconnected and apathetic toward the victim.
- C. Frustrated and feeling vulnerable, but denying need for help.
- D. Emotionally distressed and needing assistance.
Correct Answer: D
Rationale: sexual assault by rape is a crisis situation for both victim and family members and friends