Nokea
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. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
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A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Let's talk about what you're thinking.
- B. Is this something you think you can do?
- C. Are you feeling okay?
- D. Do you need more time to absorb this information?
Correct Answer: A
Rationale: Engaging the client about their thoughts addresses distraction and builds rapport.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. They may need a feeding tube.
- C. Have you tried offering different foods?
- D. Let's discuss ways to encourage their appetite.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees uses proper mechanics, reducing injury risk during transfer.