Nokea
A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.
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A nurse is assisting in interviewing a client who is being admitted from a long-term care facility. In which of the following situations should the nurse ask a closed-ended question?
- A. Determining if the client is eating a well-balanced diet
- B. Asking the client about his receptiveness to the transfer
- C. Determining how the client completes his ADLs
- D. Asking if the client took his medications this morning
- E. *
Correct Answer: D
Rationale: Closed-ended questions are useful for obtaining specific, factual information, such as whether the client took their medications.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?
- A. The client achieves optimal personal growth.
- B. The nurse forms a personal identity.
- C. The client allows the nurse to satisfy his personal needs.
- D. The nurse's needs take priority over the client's needs.
Correct Answer: A
Rationale: The goal of a therapeutic relationship is to help the client achieve personal growth and well-being.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.