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An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client?
- A. Use a nightlight in the bathroom.
- B. Keep all four side rails up at all times.
- C. Place the client in a room with a camera monitor.
- D. Place the client in a room with a camera monitor.
Correct Answer: A
Rationale: A nightlight reduces fall risk by improving visibility during nighttime bathroom trips, suitable for an alert client. Four side rails are a restraint and unsafe.
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The nurse should monitor the client with Cushing's disease for which of the following?
- A. Postprandial hypoglycemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Decreased urine calcium level.
Correct Answer: B
Rationale: Hypokalemia is common in Cushing's disease due to aldosterone excess, causing potassium loss.
A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply.
- A. Reduces myocardial oxygen consumption.
- B. Promotes reduction in respiratory rate.
- C. Prevents ventricular remodeling.
- D. Reduces blood pressure and heart rate.
- E. Reduces anxiety and fear.
Correct Answer: A,D,E
Rationale: Morphine reduces pain, which lowers myocardial oxygen demand (A), decreases blood pressure and heart rate through vasodilation and reduced sympathetic response (D), and alleviates anxiety and fear (E). It does not prevent ventricular remodeling or directly reduce respiratory rate in this context.
The nurse is planning a community health class for older adults. Which topic should the nurse prioritize?
- A. discussing and preventing polypharmacy
- B. strategies to stay physically active
- C. staying socially engaged in the community
- D. recommended immunizations
Correct Answer: A
Rationale: Polypharmacy is a critical issue in older adults, increasing the risk of adverse drug events.
What is the nurse's best action for a client with a migraine headache?
- A. Administer oxygen.
- B. Provide a quiet, dark environment.
- C. Encourage fluid restriction.
- D. Apply a warm compress.
Correct Answer: B
Rationale: A quiet, dark environment reduces stimuli that exacerbate migraine symptoms.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.