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A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom dark at night.
- B. Cover electrical outlets in the client's home with tape.
- C. Hang a monthly calendar in the client's bedroom.
- D. Place a large face clock in the client's bedroom.
Correct Answer: D
Rationale: The correct answer is D: Place a large face clock in the client's bedroom. This is important for clients with Alzheimer's disease as it helps them maintain a sense of time and routine. People with Alzheimer's often struggle with time perception, so having a clock with large, easy-to-read numbers can assist them in understanding the time of day. This can help reduce confusion and anxiety.
A: Keeping the client's bedroom dark at night may increase confusion and disorientation for someone with Alzheimer's.
B: Covering electrical outlets with tape is not relevant to caring for a client with Alzheimer's at home.
C: Hanging a monthly calendar in the client's bedroom may not be as effective as a large face clock in helping the client understand time.
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A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (C) is not directly related to ibuprofen use. Urine for white blood cells (D) is not relevant in this scenario.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.
- B. You should avoid intercourse to prevent injury to your vagina.
- C. Women your age experience thickening of the vaginal tissue.
- D. Your symptoms are likely due to decreasing estrogen levels.
Correct Answer: D
Rationale: The correct answer is D: Your symptoms are likely due to decreasing estrogen levels. As women age, estrogen levels decrease leading to vaginal dryness and itching. This is a common symptom of menopause. By acknowledging the client's symptoms are likely due to decreasing estrogen levels, the nurse shows understanding and can provide appropriate education and treatment options. Choice A is incorrect as symptoms may persist without intervention. Choice B is incorrect as it does not address the underlying cause. Choice C is incorrect as it is not a typical experience for women of that age.
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hr.
Correct Answer: A
Rationale: Correct Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching
- B. Move the client up and down in bed by holding onto the halo traction device
- C. Ensure that there is space for one finger to fit between the vest and the client's skin
- D. Loosen or tighten the screws on the device as needed for the client's comfort
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.