Nokea
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
- A. Restrain her so she will not wander in the halls
- B. Ask her roommate to call the nurse whenever she leaves the room
- C. Punish her when she gets in a bed other than her own
- D. Put her favorite picture on the door to her room
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.
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The nurse is caring for a 10-year-old child who has classic hemophilia. He is admitted with a swollen right knee that is very painful. The nurse should plan to include which of the following as a priority in the care of this child upon admission?
- A. Range-of-motion exercises to maintain joint mobility
- B. Ambulation at least three times a day to prevent immobility complications
- C. A bed cradle to reduce pain
- D. Offer 250 mL of fluid every hour to prevent hemarthrosis
Correct Answer: C
Rationale: A bed cradle keeps bedding off the painful, swollen knee (hemarthrosis), reducing discomfort, a priority in acute hemophilia management.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.
Dual diagnosis indicates that there is a substance abuse problem as well as a
- A. cross addiction
- B. mental disorder
- C. disorder of any type
- D. medical problem
Correct Answer: B
Rationale: Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.
An adult is to have a paracentesis performed today. What should the nurse do before the procedure?
- A. Encourage the client to drink large amounts of fluids
- B. Ask the client to empty her bladder just before the test
- C. Keep the client NPO until after the procedure
- D. Premedicate the client as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Fluid intake, NPO status, or premedication are not immediate pre-procedure priorities.
After a painful exacerbation of rheumatoid arthritis, a patient is to begin a walking and exercise program.
An appropriate outcome would be that the patient:
- A. Avoids exercising when there is some discomfort.
- B. Is pain free while engaging in the activity program.
- C. Walks and exercise even when the pain is severe.
- D. Exercise unless the discomfort becomes too great.
Correct Answer: D
Rationale: Exercising until discomfort becomes too great balances activity with joint protection, promoting safe participation.