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. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Drink a glass of milk before bedtime.
Correct Answer: D
Rationale: Milk contains tryptophan, promoting serotonin and melatonin production to aid sleep.
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A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply a thin layer of talc powder around the stoma before placing the appliance.
- B. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- C. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- D. I will clean around the stoma with a moisturizing soap.
Correct Answer: C
Rationale: Pressing the barrier ensures adhesion, preventing leaks and maintaining skin integrity.
A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
- A. Temperature 37.5° C (99.5° F)
- B. Client is difficult to arouse.
- C. Respiratory rate 10/min
- D. Pulse oximetry 88% on room air
- E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg
- F. Heart rate 61/min
Correct Answer: B,C,D
Rationale:
A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Increased hunger
- B. Garbled voice
- C. Sneezing
- D. Rapid chewing
Correct Answer: B
Rationale: A garbled voice suggests swallowing difficulty, a common dysphagia sign post-stroke.
A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.