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A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees ensures stability and safety during the transfer process.
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A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
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. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
A nurse is assisting with the care of a male client in the unit. Complete the following sentence by using the list of options. The client is at risk for developing ___ due to ___.
- A. Aspiration pneumonia
- B. Coughing when eating
- C. sweating
- D. increased heart beat
Correct Answer: A,B
Rationale: A: Coughing during eating increases aspiration risk. B: Indicates potential airway entry.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders.
- B. Increased concave curve of the thoracic spine.
- C. Expansion of the upper intercostal spaces.
- D. Increased convex curve of the cervical spine.
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to lateral spinal curvature.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.