Nokea
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.
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A nurse is delegating care for a client. Client has right-sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3 tasks the nurse should assign to assistive personnel.
- A. Assist the client with completing their food menu.
- B. Document the client's urine output
- C. Monitor the client for manifestations of aspiration pneumonia
- D. Initiate a referral with the speech language pathologist
- E. Instruct the client on swallowing techniques
- F. Ambulate the client.
- G. Obtain the client's vital signs.
Correct Answer: B,F,G
Rationale: Assistive personnel can document urine output, ambulate the client, and obtain vital signs, as these are low-risk tasks within their scope.
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
- A. Diminished hand-to-mouth coordination
- B. Impaired voluntary cough
- C. Unilateral ptosis
- D. Altered level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Impaired voluntary cough. Impaired voluntary cough in a client who had a stroke can indicate dysphagia, which is a common complication post-stroke. Referral to speech-language pathology is essential for assessing and managing dysphagia to prevent aspiration pneumonia and malnutrition. Diminished hand-to-mouth coordination (A) may indicate motor deficits but does not directly relate to speech and swallowing. Unilateral ptosis (C) is a drooping eyelid and is not typically a direct concern for speech-language pathology. Altered level of consciousness (D) may indicate neurological issues but does not specifically warrant a referral to speech-language pathology.
A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who has orthostatic hypotension and is receiving IV fluids
- B. A client who is receiving heparin and has an aPTT of 34 seconds
- C. A client who has Type 1 diabetes and uses an insulin pump
- D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
Correct Answer: D
Rationale: Pressure ulcer risk and nutritional concerns require interdisciplinary collaboration (e.g., dietitian, physical therapist) for comprehensive care.
A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?
- A. Physical therapist
- B. Social worker
- C. Occupational therapist
- D. Speech pathologist
Correct Answer: B
Rationale: The correct answer is B: Social worker. A social worker is essential in addressing the psychosocial aspects of oppositional defiant disorder, providing support to the child and family, and coordinating resources. Physical therapist (A) focuses on physical rehabilitation, occupational therapist (C) on activities of daily living, and speech pathologist (D) on communication issues, which are not the primary concerns in oppositional defiant disorder.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.