Nokea
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in conveying needs, enhancing teaching effectiveness.
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A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The lower end of the sling goes below the client's calves.
- B. This type of device is useful for a client who cannot assist.
- C. The sides of the sling are for the client to hold on to.
- D. The device requires the client to use upper body strength.
Correct Answer: B
Rationale: Mechanical lifts are designed for clients unable to assist, reducing injury risk.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start receiving mammograms as early as age 40.
- B. You should receive a breast ultrasound every 3 years after age 50.
- C. You should start performing monthly breast self-examinations at age 35.
- D. You should receive a breast examination from your provider each year after age 30.
Correct Answer: A
Rationale: Mammograms starting at age 40 are recommended for average-risk women.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.