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A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with his amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct Answer: B
Rationale: An expected outcome is that the client falls asleep shortly after going to bed.
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The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
- A. 5
- B. 4
- C. 3
- D. 8
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1 Total pain score-4