Nokea
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.
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A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
- B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
- C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
- D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
- A. The top of the cane is parallel to the client's wrist.
- B. When walking
- C. the client moves the cane 46 cm (18 in) forward.
- D. The client holds the cane on the stronger side of her body.
- E. The client moves her stronger limb forward with the cane.
Correct Answer: D
Rationale: Correct Answer: D: The client holds the cane on the stronger side of her body.
Rationale:
1. Holding the cane on the stronger side provides better stability and support.
2. This position allows the client to shift weight onto the cane during walking.
3. It helps to reduce pressure on the weaker side, promoting balance and preventing falls.
Incorrect Choices:
A: The top of the cane parallel to the client's wrist is not directly related to correct use.
B: Walking is a general action, not specific to correct cane use.
C: Specific measurements of cane movement are not essential for correct use.
E: Moving the stronger limb forward with the cane does not ensure proper use.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
- A. Make sure the client's room has at least six air exchanges per hour.
- B. Make sure the client wears a mask when outside her room if there is construction in the area.
- C. Place the client in a private room with negative-pressure airflow.
- D. Wear an N95 respirator when giving the client direct care.
Correct Answer: A
Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is essential for a protective environment post-allogeneic stem cell transplant to reduce the risk of infection. Increasing air exchanges helps remove airborne pathogens and maintain a clean environment. Option B is incorrect as wearing a mask outside the room is not a part of a protective environment. Option C is incorrect as negative-pressure airflow is typically used for clients with airborne infections, not for stem cell transplant clients. Option D is incorrect as N95 respirators are not routinely required for providing direct care in a protective environment setting.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?
- A. Turn the client every 2 hours.
- B. Administer an anti-cholinergic medication.
- C. Hold oral care.
- D. Increase the room's temperature.
Correct Answer: B
Rationale: The correct answer is B: Administer an anti-cholinergic medication. This is because anti-cholinergic medications can help reduce secretions in the airway, thus improving the client's breathing and reducing the noisy respirations. Turning the client every 2 hours (choice A) may provide comfort but does not address the immediate issue of airway secretions. Holding oral care (choice C) is important for overall comfort but does not directly address the client's breathing difficulty. Increasing the room's temperature (choice D) is unlikely to improve the client's respiratory distress and may even make it worse.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct Answer: D
Rationale: The correct answer is D: "Is your pain sharp or dull?" This question helps the nurse determine the characteristic of the pain, which is crucial in identifying the underlying cause. Sharp pain is often associated with acute conditions like nerve irritation, whereas dull pain may indicate musculoskeletal issues. Choices A, B, and C are important in pain assessment but do not specifically address the quality of pain. Asking about pain intensity (choice B) or radiation (choice C) can provide valuable information but do not directly address whether the pain is sharp or dull. Therefore, option D is the most appropriate for assessing the quality of the client's pain in this scenario.