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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. My advance directives can be enforced once my attorney approves them.
- C. A family member will need to witness my signature on my living will.
- D. I can name my sibling as my designee in my durable power of attorney for health care.
Correct Answer: C
Rationale: A witness, often a family member, validates the living will, reflecting procedural understanding.
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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. Speak with a loud voice while providing the information.
- C. Avoid the use of facial gestures during the instructions.
- D. Determine the client's ability to use a communication board.
Correct Answer: D
Rationale: A communication board aids expression in expressive aphasia, enhancing understanding.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has tuberculosis
- C. A client who is HIV-positive
- D. A client who has had varicella
Correct Answer: D
Rationale: Prior varicella exposure prevents shingles transmission, making this roommate safe.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Drink a glass of milk before bedtime.
Correct Answer: D
Rationale: Milk contains tryptophan, promoting serotonin and melatonin production to aid sleep.
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. Make sure four fingers fit between the restraint and the client's body.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: A
Rationale: Applying restraints over clothing prevents skin irritation and adds comfort, reducing risks of abrasions and pressure sores.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.