Nokea
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.
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A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
- A. I will no longer need regular gynecological examinations.
- B. I will have a large scar on my stomach after this procedure.
- C. I am thankful I am done having children.
- D. I should expect my periods to resume in 1 month.
Correct Answer: C
Rationale: Expressing relief about no more children suggests understanding of the procedure's outcome.
The client is experiencing delirium.
A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
- A. Echopraxia
- B. Aphasia
- C. Acute onset of confusion
- D. Inability to read
Correct Answer: C
Rationale: Acute onset of confusion is a hallmark of delirium.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?
- A. Brewed green tea
- B. Cola soft drink
- C. Hot cocoa
- D. Instant coffee
Correct Answer: C
Rationale: Hot cocoa has the least caffeine compared to tea, soda, and coffee.