Nokea
The son of a client who has Alzheimer's disease and mild hypertension.
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease and mild hypertension. Which of the following responses should the nurse make?
- A. You owe it to your mother to take care of her now that she needs you.
- B. Let me give you some information about respite care for your mother.
- C. I think you should find other family members who could help your mother.
- D. You should think about placing your mother in a long-term care facility.
Correct Answer: B
Rationale: Respite care information supports the caregiver's well-being.
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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Respond to family members about a client's condition.
- B. Determine which clients should be seen first.
- C. Clean and dress client abdominal wounds.
- D. Take vital signs on clients as they are admitted.
Correct Answer: D
Rationale: Taking vital signs is within the AP's scope, unlike triage or wound care.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
- A. Tape the tube to the child's cheek.
- B. Attach an extension tube to the site's opening prior to use.
- C. Secure the tubing to the child's abdomen.
- D. Apply water-soluble lubricant to the site.
Correct Answer: C
Rationale: Securing the tube to the abdomen prevents dislodgement.
The client has decided to stop dialysis treatment.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Ask the facility chaplain to visit the client.
- B. Discuss alternative treatment methods with the client.
- C. Support the client's decision to stop the treatment.
- D. Tell the client she should discuss this decision with her family.
Correct Answer: C
Rationale: Supporting the client's decision respects autonomy, a fundamental ethical principle.
The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.