Nokea
An adult client complains of dizziness when getting out of bed in the morning. Which instruction should the nurse give the nursing assistant regarding care of this client?
- A. Have the client wear slippers when getting out of bed.
- B. Have the client sit on the edge of the bed for a few minutes.
- C. Offer the client some juice before getting out of bed.
- D. Tell the client to stay in bed until she is no longer dizzy.
Correct Answer: B
Rationale: Sitting on the bed's edge minimizes orthostatic hypotension, reducing dizziness and fall risk during morning transitions.
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A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent.
Which of these responses by the nurse would be BEST?
- A. These things always have a way of working themselves out.'
- B. It's important for your health that you not worry too much.'
- C. You're worried that you won't be able to pay the rent?'
- D. A social worker might be able to help you with this problem.'
Correct Answer: C
Rationale: Strategy: 'BEST' indicates there may be more than one response you will like. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoid feelings (3) correct-reflective response, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic
A client with paralysis from a cerebrovascular accident (CVA).
Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?
- A. Maintain adduction of the affected shoulder.
- B. Prevent flexion of the affected extremities.
- C. Observe active range of motion (ROM) daily to all extremities.
- D. Maintain external rotation of the affected hip.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct-flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
A 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.
The nurse would be MOST concerned if the client made which of the following statements?
- A. I have blurred vision at times.'
- B. My legs and knees hurt.'
- C. My hands and feet tingle.'
- D. I think I had a migraine yesterday.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to Isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct-may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication
An adult has recently been diagnosed with chronic obstructive pulmonary disease (COPD). All of the following goals are in the teaching plan. Which will probably be most difficult for the client to achieve?
- A. Stop smoking within three months
- B. Demonstrate pursed lip breathing technique within one week
- C. Drink 2 L of fluid each day
- D. Receive vaccinations against flu and pneumonia within one month
Correct Answer: A
Rationale: Smoking cessation is the most challenging due to nicotine addiction, despite being critical for COPD management, compared to learning breathing techniques, hydration, or vaccinations.
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.