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A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?
- A. Leave the television on.
- B. Install locks at the top of doors.
- C. Place throw rugs on the floor.
- D. Schedule alternate caregivers.
Correct Answer: B
Rationale: Locks at the top of doors prevent wandering, a safety concern in Alzheimer's. TV can agitate, rugs are a fall risk, and caregiver scheduling isn't an environmental modification.
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A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
- A. A client whose injection site is scabbed
- B. A client whose injection site is firm and measures 3 mm (0.1 in)
- C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
- D. A client whose injection site is ecchymotic
Correct Answer: C
Rationale: An induration of 15 mm after 48 hours indicates a positive TB skin test, suggesting exposure or infection. Smaller indurations, scabbing, or bruising do not meet the criteria for a positive result.
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?
- A. Physical inactivity
- B. Family history of colorectal cancer
- C. High-fiber diet
- D. Age over 50 years
- E. History of diabetes mellitus
Correct Answer: B
Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.