Nokea
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.
- A. Ask a family member about the client's preferences for room arrangement
- B. Offer the client an elbow to hold, and walk a half-step ahead for guidance
- C. Say 'goodbye' when leaving the room to help orient the client
- D. Speak slowly and slightly louder so the client can understand
- E. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct Answer: B,C,E
Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.
You may also like to solve these questions
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.
The nurse is assisting in caring for a client who had a transsphenoidal hypophysectomy 48 hours ago and has developed diabetes insipidus. Which of the following prescriptions should the nurse clarify?
- A. Administer desmopressin
- B. Check the client's urine osmolarity daily
- C. Obtain a blood specimen to check the serum sodium level
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Desmopressin treats diabetes insipidus by replacing vasopressin. Checking urine osmolarity and serum sodium monitors the condition. Trendelenburg position is inappropriate as it may increase intracranial pressure post-hypophysectomy.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated hepatic enzymes
Correct Answer: D
Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.
The nurse is caring for a client with anorexia nervosa. After experiencing a weight gain of 2 lb (0.9 kg), the client states, 'See what you have done to me? I am fatter and uglier than ever.' Which of the following actions would be most appropriate for the nurse to take?
- A. Acknowledge the client's distress and explore the client's underlying feelings.
- B. Remind the client that gaining weight is a criterion for discharge home.
- C. Encourage the client to write about the client's feelings in a journal
- D. Recommend the client receive cognitive behavioral therapy.
Correct Answer: A
Rationale: Acknowledging distress and exploring feelings builds trust and addresses body image issues. Discharge criteria , journaling , or therapy are less immediate.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.