Nokea
After suffering a massive cerebral hemorrhage, a client of American Indian descent is not expected to survive. The family arrives at the hospital. In conversation with the family, they report they observe most of their religious and cultural traditions. Which of the following interventions by the nursing staff would be most appropriate?
- A. Offer the family a private room to sit together.
- B. Discourage the family from sitting with their loved one prior to death.
- C. Discuss the possibility of transferring the client home for the death.
- D. Encourage the family to assist in the care of the dying client.
Correct Answer: A
Rationale: Traditional American Indians prefer to mourn in private, often away from the dying client. Offering a private room respects this cultural practice.
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A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which response is most appropriate?
- A. The incidence of shingles in people your age is not overly common, so vaccination is unnecessary.'
- B. The vaccination has not yet been approved for use in the older adults.'
- C. Because of the incidence of shingles in your age group, you should consider taking the vaccination.'
- D. The vaccination is expensive but will provide lifelong immunity.'
Correct Answer: C
Rationale: The vaccination should be considered by high-risk populations. About 50% of individuals over age 80 years will have the disease. The vaccination has been approved for use. The immunity provided is anticipated to last for 6 years.
A client is scheduled to undergo a prostate biopsy. When providing education concerning postoperative care related to the procedure, which of the following should be included?
- A. Avoid strenuous activity for 24 hours.
- B. There may be discomfort for 24-48 hours after the procedure.
- C. The client can immediately return to his preprocedure activity level.
- D. The names of sexual contacts must be collected.
Correct Answer: B
Rationale: The client might experience discomfort for 1-2 days after the procedure. Strenuous activity is avoided for only about 4 hours, not 24, and sexual contacts are irrelevant.
Which situation makes the nurse suspect the client has glaucoma?
- A. An automobile accident because the client did not see the car in the next lane.
- B. The cake tasted funny because the client could not read the recipe.
- C. The client has been wearing mismatched clothes and socks.
- D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
Correct Answer: A
Rationale: Glaucoma causes peripheral vision loss, which could prevent seeing a car in the next lane, leading to an accident, aligning with its typical presentation.
The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?
- A. Obtain a sample of the drainage for culture and sensitivities.
- B. Determine any allergic reactions to any medications taken recently.
- C. Inquire how the poison ivy/oak plants were destroyed.
- D. Assess for any temperature elevation since the last visit to the clinic.
Correct Answer: D
Rationale: Temperature elevation could indicate a secondary infection, a common complication needing prompt assessment.
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client?
- A. Apply an ice pack to the right hand
- B. Place the hand in cool water
- C. Be sure to rupture any blister formation
- D. Go immediately to the doctor's office
Correct Answer: B
Rationale: Cool water reduces heat and pain without damaging tissue, unlike ice or rupturing blisters, which can worsen the injury.