Nokea
A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
- A. A young girl wrapped in a shroud fell asleep on a bed of clouds.
- B. I was born on April 3, 1967, in Johnstown Community Hospital.
- C. Apple, chair, and pencil are the words you just stated.
- D. I ate oatmeal with wheat toast and orange juice for breakfast.
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.
You may also like to solve these questions
A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's teaching?
- A. Connect a light to flash when your doorbell rings.
- B. Label your faucet knobs with hot and cold signs.
- C. Ask a friend to drive you to your follow-up appointments.
- D. Use a natural gas detector with an audible alarm.
Correct Answer: B
Rationale: Cerebellar impairment affects coordination and balance, not vision or hearing, so labeling faucets helps the client safely navigate daily tasks. The other options address sensory impairments unrelated to cerebellar dysfunction.
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication should prompt the nurse to contact the health care provider?
- A. Weak pedal pulses
- B. Nausea and vomiting
- C. Increased thirst
- D. Hives on the chest
Correct Answer: B
Rationale: Nausea, vomiting, severe headache, photophobia, or altered consciousness post-LP indicate increased intracranial pressure, requiring immediate provider notification. The other findings are not specific to LP complications.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
- A. Educate the client about strict bedrest after the procedure.
- B. Obtain a prescription for intravenous fluids.
- C. Assess the client's gag reflex.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: Intravenous fluids promote excretion of contrast medium, protecting the kidneys in clients with renal insufficiency. Bedrest is not required, gag reflex is unaffected, and an indwelling catheter is unnecessary unless otherwise indicated.
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
- A. You may return to your previous activity level immediately.
- B. You are radioactive and must use a private bathroom.
- C. Frequent assessments of the injection site will be completed.
- D. We will be monitoring your renal function closely.
Correct Answer: A
Rationale: No special precautions are needed after SPECT, as radioisotopes are eliminated in urine without requiring monitoring or activity restrictions. The other options are unnecessary.
A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.