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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.
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A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)
- A. Long-term memory loss
- B. Slower processing time
- C. Increased sensory perception
- D. Decreased risk for infection
- E. Change in sleep patterns
Correct Answer: B,E
Rationale: Normal
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Glasgow Coma Scale score changes
- B. Abnormal flexion or extension
- C. Changes in cognition or speech
- D. Pinpoint, dilated, and nonreactive pupils
- E. Stable vital signs
Correct Answer: A,B,C,D
Rationale: Changes in Glasgow Coma Scale score, abnormal posturing, altered cognition or speech, and nonreactive pupils indicate neurological deterioration, requiring urgent provider notification. Stable vital signs do not necessitate immediate action.
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching?
- A. Place items in warm water to increase your circulation.
- B. Bathe in warm water to increase your circulation.
- C. Look at the placement of your feet when walking.
- D. Walk barefoot to decrease pressure effects from your shoes.
Correct Answer: C
Rationale: Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. Instructing the client to look at the placement of their feet compensates for this sensory loss and reduces fall risk. Warm water poses a risk of thermal injury, and walking barefoot increases the risk of injury due to lack of protection.
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.
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care?
- A. Check bath water temperature with a thermometer.
- B. Provide the client with assistance when ambulating.
- C. Place elastic support hose on the client's legs.
- D. Allow the client to use a white board to ask questions.
Correct Answer: B
Rationale: Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. Providing ambulation assistance helps prevent injury by ensuring the client has support while walking. The other interventions do not address the balance and coordination issues caused by hypoactive reflexes.