Nokea
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching?
- A. Place items in warm water to increase your circulation.
- B. Bathe in warm water to increase your circulation.
- C. Look at the placement of your feet when walking.
- D. Walk barefoot to decrease pressure effects from your shoes.
Correct Answer: C
Rationale: Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. Instructing the client to look at the placement of their feet compensates for this sensory loss and reduces fall risk. Warm water poses a risk of thermal injury, and walking barefoot increases the risk of injury due to lack of protection.
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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.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching?
- A. Avoid caffeine-containing substances for 12 hours before the test.
- B. Increase your fluid intake before and after the test.
- C. Do not take your cardiac medication the morning of the test.
- D. Remove your dentures and any metal before the test begins.
Correct Answer: A
Rationale: Caffeine is a central nervous system stimulant that may alter PET scan results, so it should be avoided for 12 hours prior. Increased fluid intake is unnecessary, cardiac medications should be continued, and metal removal is relevant for MRI, not PET.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching?
- A. I must increase my fluids because of the dye used for the MRI.
- B. My urine will be radioactive so I should not share a bathroom.
- C. I can return to my usual activities immediately after the MRI.
- D. My gag reflex will be tested before I can eat or drink anything.
Correct Answer: C
Rationale: No post-procedure restrictions are imposed after an MRI, allowing the client to resume normal activities. No dyes or radioactive materials are used, and the gag reflex is unaffected by the procedure.
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse perform when educating this client about newly prescribed medications?
- A. Help the client identify each medication by its color.
- B. Provide written materials with large print size.
- C. Sit on the client's right side and speak into the right ear.
- D. Allow the client to use a white board to ask questions.
Correct Answer: C
Rationale: The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear to compensate for the hearing impairment caused by left temporal lobe damage. The other interventions do not directly address the hearing deficit associated with this condition.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
- A. Shingles on the client's back
- B. Client is claustrophobic
- C. Absence of intravenous access
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.