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A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This is the most appropriate intervention as older adults with dementia may have difficulty expressing their needs and may forget to use the bathroom. Establishing a routine for bathroom breaks can prevent accidents and promote comfort. Choice A is incorrect as isolating the client may increase agitation. Choice B is incorrect as using all four side rails can be a safety hazard and restrict mobility. Choice C is incorrect as it does not address the specific issue of wandering at night.
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A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous, low-pitched gurgling sounds heard over the trachea and bronchi. This finding indicates the presence of secretions or mucus in the larger airways. Crackles (B) are discontinuous, popping sounds heard during inspiration and indicate fluid in the alveoli. Wheezing (C) is a high-pitched whistling sound that occurs when air flows through narrowed airways. Friction rub (D) is a grating or rubbing sound heard during inspiration and expiration, caused by inflammation of the pleural surfaces. The other choices are not consistent with the described findings.
A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?
- A. The nurse stands tall before talking.
- B. The nurse paces back and forth while making the speech.
- C. The nurse looks down at her notes for the duration of the talk.
- D. The nurse taps her foot repeatedly during the speech.
Correct Answer: A
Rationale: Standing tall with good posture conveys confidence and authority while speaking.
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 collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?
- A. Note dry, flaky skin as an expected finding.
- B. Examine the back before the general inspection of the skin.
- C. Pinch up a fold of skin to check for turgor.
- D. Use a penlight to examine the back in greater detail.
Correct Answer: A
Rationale: The correct answer is A. Dry, flaky skin is a common finding in older adults due to decreased oil gland activity. The nurse should note this as an expected finding because it is often a normal part of aging and not necessarily indicative of a health concern. Option B is unnecessary as the nurse can inspect the back during the general skin assessment. Option C, checking skin turgor, is not relevant to dry, flaky skin. Option D, using a penlight for detailed examination, is excessive for this situation.
A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?
- A. You know this is not the right time for me to do this.
- B. Everyone knows there are others who can chair this committee better than I could.
- C. Can you tell me why you chose me?
- D. I decline the opportunity at this time.
Correct Answer: D
Rationale: Assertive communication is direct and respectful, clearly stating a decision without being passive or aggressive.