Nokea
A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care?
- A. Provide a call button that requires only light pressure to activate.
- B. Ensure the path to the bathroom is free from equipment.
- C. Encourage the client to season food to stimulate nutritional intake.
- D. Provide written instructions in large print for the client.
Correct Answer: B
Rationale: Clearing the path to the bathroom ensures safe ambulation for a client with sensory perception changes, reducing fall risk. The other options do not directly address the safety concerns related to impaired sensory perception.
You may also like to solve these questions
A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
- A. A young girl wrapped in a shroud fell asleep on a bed of clouds.
- B. I was born on April 3, 1967, in Johnstown Community Hospital.
- C. Apple, chair, and pencil are the words you just stated.
- D. I ate oatmeal with wheat toast and orange juice for breakfast.
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
- A. Creatine phosphokinase (CPK) of 100 IU/L.
- B. Atrioventricular graft.
- C. Blood urea nitrogen (BUN) of 50 mg/dL.
- D. Internal insulin pump.
Correct Answer: D
Rationale: Metal devices like an internal insulin pump can interfere with MRI imaging and be displaced by magnetic forces, necessitating cancellation. CPK, BUN levels, and atrioventricular grafts do not contraindicate MRI.
A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.
A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete?
- A. Palpate bilateral lower extremity pulses.
- B. Obtain orthostatic blood pressure readings.
- C. Perform a fundoscopic examination.
- D. Assess the gag reflex prior to eating.
Correct Answer: A
Rationale: Cerebral angiography involves threading a catheter through the femoral artery, and the extremity is immobilized post-procedure. Checking bilateral lower extremity pulses ensures adequate circulation. Orthostatic blood pressure readings are not feasible due to bedrest, and fundoscopic examination or gag reflex assessment is unrelated to the procedure.
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
- A. Ask the client about any allergies
- B. Evaluate the client's renal function
- C. Ensure informed consent is present
- D. Assess breath sounds
- E. Assess hematocrit and hemoglobin levels
Correct Answer: A,B,C
Rationale: Asking about allergies (especially to iodine or shellfish), evaluating renal function, and ensuring informed consent are critical to safely administer iodine-based contrast. Assessing breath sounds or hematocrit/hemoglobin is unrelated to CT preparation.