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A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
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An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
A nurse prepared the 9:00 A.M. medications for his clients and then was called off the unit briefly before he was able to administer them. Who may administer the medications to the clients now?
- A. Any licensed nurse assigned to the unit and familiar with the clients
- B. A pharmacy technician certified to administer medications
- C. The nurse who prepared them
- D. The nurse manager of the unit
Correct Answer: C
Rationale: The nurse who prepared the medications must administer them to ensure accountability and familiarity with the preparation.
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
An adolescent client has been hospitalized for 2 months for an eating disorder. She asks the nurse what to tell her classmates about her long absence. The nurse can best help the client by:
- A. Having her practice changing the subject when asked personal questions
- B. Helping her invent a believable explanation for her absence
- C. Engaging her in role playing activities that are likely to occur
- D. Encouraging her to share her experiences with those who ask
Correct Answer: C
Rationale: Role-playing helps the client prepare for social interactions, building confidence in handling questions about her absence.
Which activity is appropriate to assign to a certified nursing assistant?
- A. Evaluate vital signs.
- B. Monitor tube feedings.
- C. Assist with activities of daily living (ADLs).
- D. Discuss discharge instructions.
Correct Answer: C
Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.