Nokea
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Drink a glass of milk before bedtime.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Take a 1-hour nap each day.
Correct Answer: A
Rationale: Milk contains tryptophan, which promotes sleepiness.
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A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Clammy skin
- D. Tortuous veins
Correct Answer: A
Rationale: Calf swelling is a common sign of deep-vein thrombosis (DVT) and requires immediate reporting due to risk of complications.
A nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. Why do you think they're not eating?
- C. I'm sure it's nothing serious and their appetite will return soon.
- D. They may need a feeding tube.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll learn to notice the sensation of muscle tension.
- C. I think about my grandfather's farm to reduce pain.
- D. I listen to my favorite music to take my mind off the pain.
Correct Answer: C
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. The best time to perform a breast self-examination is on the first day of my period.
- B. I can expect to have regular periods until I am in menopause.
- C. I might have headaches due to a decline in my estrogen levels.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: C
Rationale: Declining estrogen levels during perimenopause can cause headaches.