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A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
- A. Explain to the client what is about to happen.
- B. Make sure the room temperature is cool.
- C. Provide music as an environmental distraction.
- D. Inform the client that the provider will examine sensitive areas first.
Correct Answer: A
Rationale: The correct answer is A. The nurse should explain to the client what is about to happen to ensure the client feels informed and comfortable throughout the physical examination. This helps establish trust and promote client autonomy. Choice B is incorrect because older adults may prefer a warmer room temperature for comfort. Choice C is incorrect as not all clients may find music distracting or helpful during the examination. Choice D is incorrect because informing the client about examining sensitive areas first may cause unnecessary anxiety.
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A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve?
- A. Instruct the client to look up and down without moving his head.
- B. Observe the client's ability to smile and frown.
- C. Evaluate the client's pupillary reaction to light.
- D. Ask the client to shrug his shoulders against passive resistance.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's pupillary reaction to light. The third cranial nerve, also known as the oculomotor nerve, controls the pupillary response by constricting the pupil when exposed to light. By observing the client's pupillary reaction to light, the nurse can assess the function of the third cranial nerve. This test specifically targets the parasympathetic fibers of the nerve, which control pupillary constriction.
Choice A (Instruct the client to look up and down without moving his head) would assess the function of the fourth cranial nerve (trochlear nerve).
Choice B (Observe the client's ability to smile and frown) would assess the function of the seventh cranial nerve (facial nerve).
Choice D (Ask the client to shrug his shoulders against passive resistance) would assess the function of the eleventh cranial nerve (accessory nerve).
Therefore, choices A, B, and D are
A nurse is caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
- A. Assist the client back into bed and apply restraints.
- B. Call the family and ask them to make arrangements for someone to sit with the client.
- C. Check the client for injuries.
- D. Obtain a prescription for medication to sedate the client.
Correct Answer: C
Rationale: The correct answer is C: Check the client for injuries. This is the most appropriate action as it ensures the client's safety and well-being. By checking for injuries, the nurse can assess the extent of harm and provide necessary medical attention promptly. It also helps in determining if further interventions are required.
Choice A is incorrect because restraints should not be applied without proper assessment. Choice B is incorrect as the priority is to address the immediate physical needs of the client. Choice D is incorrect as sedation should not be the first response to a fall.
A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following nursing responses uses reflection?
- A. You seem upset about your blood pressure.'
- B. What time do you take your medication?'
- C. How do you feel when you take the medication?'
- D. I understand your reluctance to use medication.'
Correct Answer: A
Rationale: Reflection restates the client's emotions, encouraging further discussion.