Nokea
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?
- A. Limit the number of choices for the client.
- B. Use written signs to assist the client with locating the bathroom.
- C. Provide a stimulating environment for the client.
- D. Use confrontation to manage the client's behavior.
Correct Answer: A
Rationale: Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as 'Would you like tea or juice?' instead of an open-ended question, helps reduce confusion and frustration.
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A nurse is reinforcing teaching with a client who has a new prescription for metformin. Which of the following adverse effects should the nurse include?
- A. Weight gain
- B. Metallic taste
- C. Hypotension
- D. Hyperglycemia
Correct Answer: B
Rationale: Metformin can cause a metallic taste, a common side effect that the client should be aware of when starting the medication.
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
- A. Instruct the client to hold the drainage bag at waist height when ambulating.
- B. Coil the tubing on the bed above the collection bag.
- C. Collect a sterile specimen from the urinary drainage bag.
- D. Secure the tubing with adhesive tape to the lower abdomen.
Correct Answer: D
Rationale: Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.
A nurse is caring for a client who has a new diagnosis of pheochromocytoma. Which of the following findings should the nurse expect?
- A. Hypertension
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Hypertension is a hallmark symptom of pheochromocytoma due to excessive catecholamine production.
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
A nurse is reinforcing teaching with a client who has a new prescription for a testosterone patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the scrotum.
- B. Remove the patch after 12 hours.
- C. Apply the patch to the upper arm.
- D. Leave the patch on for 48 hours.
Correct Answer: C
Rationale: Applying the testosterone patch to the upper arm (or other recommended sites) ensures effective hormone absorption.