Nokea
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
- A. Ask the client how strong she feels today.
- B. Ask the client if she has been out of bed today.
- C. Check the client's pedal pulses and feet for edema.
- D. Ask the client to push her legs and feet against the nurse's palms.
Correct Answer: D
Rationale: The correct answer is D. Asking the client to push her legs and feet against the nurse's palms is a direct assessment of the client's muscle strength. This action provides a more objective measure of strength compared to subjective responses (A) or general activity level (B). Checking pedal pulses and feet for edema (C) assesses circulation and fluid status, not strength. Asking the client to perform a physical task (D) allows for a practical evaluation of strength level.
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A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh-Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?
- A. Leavened bread
- B. Eggs
- C. Milk
- D. Caffeinated coffee
Correct Answer: D
Rationale: The correct answer is D: Caffeinated coffee. Seventh-Day Adventists typically avoid caffeine due to health beliefs. Coffee contains caffeine, which is considered a stimulant and is restricted. Leavened bread (A) is not specifically restricted. Eggs (B) and milk (C) are generally accepted. In summary, the other choices are incorrect because they are not specifically restricted by the Seventh-Day Adventist church.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. This stage in Erikson's theory occurs during school age (6-11 years), where children develop a sense of competence and mastery in their skills and tasks. Considering this stage in the planning for a child recovering from an asthma attack is crucial. By emphasizing the child's abilities and encouraging them to engage in self-care activities, the nurse can promote a sense of industry and competence, which can boost the child's self-esteem. Choices A, B, and D are not directly related to the developmental stage of school-age children and do not address the specific needs and challenges this age group faces. Autonomy vs. shame and doubt (A) is more relevant to toddlers, Initiative vs. guilt (B) is more relevant to preschoolers, and Identity vs. role confusion (D) is more relevant to adolescents.
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.
A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.