Nokea
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
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A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.