Nokea
A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?
- A. Auscultate for Korotkoff's sounds.
- B. Perform a Romberg test.
- C. Check the function of cranial nerve V.
- D. Inspect for the presence of clubbing.
Correct Answer: B
Rationale: The correct answer is B: Perform a Romberg test. This test evaluates the client's ability to maintain balance with eyes closed, which is essential for safe ambulation in a client with ataxia. Auscultating for Korotkoff's sounds (A) is related to blood pressure assessment, not ambulation. Checking cranial nerve V function (C) is important for facial sensation and chewing, not directly related to ambulation. Inspecting for clubbing (D) is related to respiratory or cardiovascular conditions, not relevant to assessing ambulation.
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A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
- A. They'll protect your legs and heels from skin breakdown.
- B. They'll help keep you warm immediately after your surgery.
- C. They'll improve your circulation to keep blood from pooling in your legs.
- D. They'll make it easier for you to do leg exercises after your surgery.
Correct Answer: C
Rationale: Correct Answer: C. They'll improve your circulation to keep blood from pooling in your legs.
Rationale:
1. Antiembolism stockings apply gentle pressure to the legs, promoting blood flow.
2. Improved circulation helps prevent blood clots by reducing the risk of venous stasis.
3. By preventing blood pooling, the stockings decrease the chances of deep vein thrombosis.
Incorrect Choices:
A. Skin breakdown prevention is not the primary purpose of antiembolism stockings.
B. Keeping warm is not the main function of these stockings.
D. While leg exercises are important post-surgery, it is not the main reason for using antiembolism stockings.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Turn and position each client every 2 hr.
- B. Identify the clients at greatest risk for development of pressure ulcers.
- C. Use a barrier cream when performing perineal care.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: B
Rationale: The correct answer is B: Identify the clients at greatest risk for development of pressure ulcers. This is the priority because it allows for targeted interventions to be implemented for those most vulnerable, maximizing resources and preventing potential harm. Turning and positioning clients, using barrier creams, and ensuring adequate nutrition are all important aspects of pressure ulcer prevention, but they should be tailored based on individual risk assessment. Supervising nutritional intake is crucial, but not the immediate priority in preventing pressure ulcers. Identifying high-risk clients allows for proactive measures to be taken, making it the most critical step in meeting the National Safety Goal.
A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?
- A. Generativity versus stagnation
- B. Identity versus role diffusion
- C. Intimacy versus isolation
- D. Trust versus mistrust
Correct Answer: C
Rationale: The correct answer is C: Intimacy versus isolation. According to Erikson's psychosocial theory, the stage of intimacy versus isolation occurs in young adulthood. This stage focuses on forming close relationships and commitments with others. This is a critical time for individuals to develop intimate relationships and establish long-term commitments. Choosing option C is correct as it aligns with the primary task of this stage.
A: Generativity versus stagnation occurs in middle adulthood and focuses on contributing to society.
B: Identity versus role diffusion happens in adolescence and centers on forming a sense of self.
D: Trust versus mistrust is in infancy and relates to developing trust in others.
Thus, option C is the most appropriate choice for the stage involving establishing relationships with commitment.