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A nurse is caring for a client scheduled for a functional assessment who asks, 'What is the purpose of this assessment?' How should the nurse most appropriately respond to the client?
- A. It is a test that determines which activities you feel most comfortable performing
- B. It is a tool that is used to determine your maximum level of self-sufficiency
- C. It is a tool that is used to assess what services you will need a home health aide to perform for you
- D. It is a tool used by insurance companies to determine qualifications for medical reimbursement
Correct Answer: B
Rationale: The correct answer is B: It is a tool that is used to determine your maximum level of self-sufficiency. The purpose of a functional assessment is to evaluate a person's ability to perform daily activities independently. By determining the client's level of self-sufficiency, healthcare providers can tailor care plans to support and enhance the client's functional abilities.
Explanation of other choices:
A: Incorrect. The assessment is not about comfort but rather about assessing functional abilities.
C: Incorrect. The assessment focuses on the client's abilities, not the services they may need from a home health aide.
D: Incorrect. While assessments may impact insurance reimbursement, the primary purpose is not insurance-related but rather focused on the client's functional abilities.
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A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?
- A. Blunt force trauma
- B. Hollow organ damage
- C. Post-trauma stress disorder
- D. Penetrating injuries
Correct Answer: D
Rationale: The correct answer is D: Penetrating injuries. High-order explosives cause secondary injuries like shrapnel or debris penetrating the body leading to penetrating injuries. Blunt force trauma (A) results from direct impact, not explosions. Hollow organ damage (B) is more likely with crush injuries. Post-trauma stress disorder (C) is a psychological response, not a physical injury. Therefore, the nurse should anticipate penetrating injuries as a result of the blast.
A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
- A. Chew tablet well before swallowing
- B. If you experience chest pain, call your physician immediately
- C. Take daily to prevent headaches
- D. Repeat dose in 1 hour for unrelieved headache
Correct Answer: B
Rationale: The correct answer is B: If you experience chest pain, call your physician immediately. This is crucial because Sumatriptan can sometimes cause chest pain or tightness as a side effect, which could indicate a serious issue like a heart problem. Instructing the client to contact their physician immediately ensures prompt medical attention if such symptoms occur, potentially preventing a serious complication. Choices A, C, and D are incorrect. A: Chewing Sumatriptan tablets is not recommended as it may alter the drug's absorption rate. C: Sumatriptan is not meant to be taken daily for headache prevention; it is used for acute migraine attacks. D: Repeating the dose in 1 hour is not advised as it can increase the risk of side effects and medication overuse headaches.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.
The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY
- A. Going automatically into the client's bedroom
- B. Thanking the client for arranging a home visit
- C. Arranging mutual future visits
- D. Asking how they are managing at home
- E. Sitting down and discussing with the client and family members
Correct Answer: C,D,E
Rationale: The correct actions (C, D, E) are appropriate for the initial home care visit for a client with diabetes. C is correct because arranging mutual future visits establishes continuity of care. D is correct since asking about home management helps assess the client's self-care abilities. E is essential as it promotes open communication and involvement of the client and family in the care plan. A is incorrect as entering the client's bedroom without permission violates privacy. B is incorrect as it is general politeness and not specific to diabetes care.
A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?
- A. Assisting the client with active range of motion exercises
- B. Maintaining strict bed rest to minimize cerebral blood flow
- C. Monitoring vital signs and neurological status frequently
- D. Administering anticoagulant medications as prescribed
Correct Answer: C
Rationale: The correct answer is C: Monitoring vital signs and neurological status frequently. This is crucial in caring for a client who has experienced a hemorrhagic stroke as it allows for early detection of any changes in condition such as increased intracranial pressure or neurological deterioration. Vital signs provide important information about the client's overall condition, while neurological status assessments help in evaluating brain function and detecting any signs of worsening stroke symptoms. This intervention is essential for prompt intervention and preventing further complications.
Incorrect answers:
A: Assisting the client with active range of motion exercises - This is not a priority in the acute phase of a hemorrhagic stroke as it can potentially worsen the condition.
B: Maintaining strict bed rest to minimize cerebral blood flow - While bed rest is important, strict bed rest may not be necessary, and minimizing cerebral blood flow is not the primary goal.
D: Administering anticoagulant medications as prescribed - Anticoagulants are contraindicated in hemorrhagic strokes as