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An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
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A client scheduled for electroconvulsive therapy tells the nurse, 'I'm so afraid. What will happen to me during the treatment?' Which of the following statements is most therapeutic for the nurse to make?
- A. You will be given medicine to relax you during the treatment
- B. The treatment will produce a controlled tonic clinic seizure
- C. The treatment can produce nausea and headache
- D. You can expect to be sleepy and confused for a time after the treatment
Correct Answer: A
Rationale: Explaining that medication will relax the client addresses their fear and provides reassurance about the procedure's safety, making it the most therapeutic response.
A client with insulin-dependent diabetes takes 20 units NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
- A. 8 a.m.
- B. 10 a.m.
- C. 3 p.m.
- D. 5 a.m.
Correct Answer: C
Rationale: NPH insulin peaks 6-12 hours after administration (1-3 p.m.), making 3 p.m. the time to watch for hypoglycemia. Other times are outside the peak window.
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
- A. Maintaining and preserving function
- B. Anticipating side effects of therapy
- C. Supporting coping with limitations
- D. Ensuring compliance with medications
Correct Answer: A
Rationale: Maintaining and preserving function. Preserving joint function is critical for quality of life in arthritis.
A nurse is collecting data on a 58-year-old client with blurred vision and reduced visual fields. The nurse finds which manifestation most concerning?
- A. Difficulty adjusting to dimmed lights
- B. Extreme eye pain
- C. Gradual loss of peripheral vision
- D. Opaque appearance of lens
Correct Answer: B
Rationale: Extreme eye pain (B) suggests acute conditions like glaucoma, requiring urgent attention. Difficulty in dim light (A), peripheral vision loss (C), and cataracts (D) are less acute.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.