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The client has quadriplegia.
A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
- A. Place the client's glasses on the bedside table.
- B. Place the call light within the client's reach.
- C. Check on the client every 4 hr.
- D. Place the client in a room near the nurses' station.
Correct Answer: B
Rationale: Placing the call light within reach ensures the client can summon help.
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The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
A nurse is providing care to a client who is preparing to undergo surgery. The client inquires about advance directives. Which of the following statements should the nurse make?
- A. Advance directives are the same as a consent form for health care treatment.
- B. Advance directives protect your right to make your own health care decisions.
- C. Advance directives must be approved by your lawyer.
- D. Advance directives are for clients who have life-threatening conditions.
Correct Answer: B
Rationale: Advance directives ensure client autonomy in health care decisions.
A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
- A. Difficulty swallowing
- B. Constipation
- C. Urinary retention
- D. Clenched teeth
Correct Answer: D
Rationale: Clenched teeth indicate ongoing pain despite the epidural.
The client has decided to stop dialysis treatment.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Ask the facility chaplain to visit the client.
- B. Discuss alternative treatment methods with the client.
- C. Support the client's decision to stop the treatment.
- D. Tell the client she should discuss this decision with her family.
Correct Answer: C
Rationale: Supporting the client's decision respects autonomy, a fundamental ethical principle.
The client has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin.
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
- A. You will suffer serious health issues if you don't take your medication.
- B. Have you considered how your decision to refuse medication will affect your family?
- C. I'd like to hear your thoughts about giving yourself this medication.
- D. Why don't you want to learn how to give yourself your medication?
Correct Answer: C
Rationale: Exploring the client's thoughts promotes understanding and respects autonomy.