Nokea
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
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A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching?
- A. Carry your newborn back to the nursery in your arms when you need to rest.
- B. Request that the nurses show their nursing license prior to removing your newborn from the room.
- C. Alert the staff if any of your newborn's identification bands are missing.
- D. Leave your newborn in the bassinet in your room while you use the bathroom.
Correct Answer: C
Rationale: Missing ID bands increase abduction risk, requiring immediate staff notification.
A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should leave my steri-strips on until they fall off.
- B. I should expect to have nausea for several days.
- C. I should eat a high-fat diet for several weeks.
- D. I should expect to have diarrhea until my diet changes.
Correct Answer: A
Rationale: Leaving steri-strips on until they fall off promotes proper healing.
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 reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?
- A. The client's extremity should be elevated after the cast is applied.
- B. The client should use a hair dryer on a warm setting to relieve itching inside the cast.
- C. The client should keep the cast covered until it is dry.
- D. The client can shower with the cast after 24 hr.
Correct Answer: A
Rationale: Elevating the extremity reduces swelling post-cast application.
The client reports feeling stress.
A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?
- A. Recurring urinary tract infections
- B. A recent move to a new city
- C. Report of feeling depressed
- D. Lack of nutritional knowledge
Correct Answer: B
Rationale: A recent move is an external stressor, unlike internal health or knowledge factors.