Nokea
An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
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The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.
- A. Add high-protein foods to diet
- B. Consume high-carbohydrate meals
- C. Eat small, frequent meals
- D. Increase intake of fluids with meals
- E. Lie down after eating
Correct Answer: A,C
Rationale: High-protein foods and small, frequent meals slow gastric emptying, preventing dumping syndrome. High-carb meals and fluids with meals speed emptying, and lying down delays digestion, worsening symptoms.
The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
- A. You know that extraterrestrials are make-believe.'
- B. Call his physician and report this visual hallucination.
- C. Ignore his comment and change the subject.
- D. You think someone is coming after you?'
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.
The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?
- A. I can begin driving my car again after I have been taking this medication for 2 weeks
- B. I need to contact my health care provider if I develop a rash while taking this medication
- C. I should report any new or increased anxiety I experience while taking this medication
- D. I understand that drowsiness is an adverse effect of this medication that may improve over time.
Correct Answer: A
Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.
The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
An adult client who had a cervical laminectomy is returned to her room on the nursing care unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. The nurse should position the client in which of the following positions?
- A. Supine
- B. Semi-reclining
- C. Side-lying
- D. Prone
Correct Answer: C
Rationale: Side-lying position promotes comfort and maintains spinal alignment post-cervical laminectomy, reducing strain on the surgical site. Supine or prone positions may increase pressure on the neck, and semi-reclining is less optimal for spinal stability.