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A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Encourage socialization as a distractor when the client becomes agitated.
- B. Limit instructions to two steps at a time.
- C. Vary the staff providing care for the client
- D. Encourage independence in ADLs.
Correct Answer: B
Rationale: Limiting instructions to two steps accommodates cognitive decline in Alzheimer's, enhancing comprehension and reducing frustration.
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A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will need to fast for 2 hours before the procedure.
- B. You will have the bone marrow taken from your femur.
- C. You will not receive a local anesthetic agent for this procedure.
- D. I will hold pressure on the site after the procedure.
Correct Answer: D
Rationale: Holding pressure on the site post-procedure prevents bleeding, a standard part of bone marrow aspiration care.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Keep both arms below the level of the client's heart.
- B. Obtain blood pressure readings using the client's right arm.
- C. Use the client's left arm to obtain blood samples.
- D. Limit range-of-motion exercises with the affected arm
Correct Answer: C
Rationale: Using the left arm for blood samples avoids trauma to the right arm, reducing the risk of lymphedema after a right mastectomy.
A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
- A. I will lie down for 30 minutes after each meal.
- B. I will increase vitamin C intake by drinking orange juice.
- C. I will sleep flat on my back at night.
- D. I will eat six small meals each day.
Correct Answer: D
Rationale: Eating six small meals reduces stomach pressure and reflux, indicating understanding of GERD management.
A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?
- A. Testicular
- B. Skin
- C. Prostate
- D. Colorectal
Correct Answer: A
Rationale: Testicular self-examination is recommended for young males (e.g., 18-year-olds) to detect early signs of testicular cancer.
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.