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. Avoid the use of facial gestures during the instructions.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Provide the teaching without expecting the client to respond.
Correct Answer: B
Rationale: A communication board can aid clients with expressive aphasia in understanding and responding.
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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection
- B. Providing postmortem care for a client who has just died
- C. Suctioning a tracheostomy for a client who has a recent head injury
- D. Changing a peripheral IV dressing for a client who is postoperative
Correct Answer: B
Rationale: Postmortem care is within the AP's scope; medication administration and invasive procedures are not.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Closing the client's eyes
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Removing dentures distorts facial appearance, requiring intervention.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. You can allow your family to visit as often as you wish.
- B. Tell me your expectations about activities related to the end-of-life.
- C. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: B
Rationale: Understanding the client's expectations guides personalized end-of-life care.