Nokea
An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client's spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?
- A. Reassure the spouse that the client will be well cared for and provide information about the facility's care practices.
- B. Inform the spouse that care will be adjusted based on the client's condition and needs.
- C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
- D. Suggest that the spouse speak with other family members for reassurance.
Correct Answer: A
Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility's care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.
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The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
- A. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7
- B. Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg
- C. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg
- D. Viral meningitis whose temperature changed from 101° F (38.3 C) to 102° F (38.9C)
Correct Answer: D
Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse. Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.
When deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factor is most important for the nurse to consider?
- A. Nurse Practice Act of the State
- B. The role of nurses as client advocates
- C. Standards of clinical nursing practice
- D. Personal value system
Correct Answer: B
Rationale: The correct answer is B. The role of nurses as client advocates is crucial when considering the impact of a strike on patient care. Nurses have a responsibility to advocate for their patients' well-being at all times. Choices A, C, and D, although important, are not the most critical factor to consider in this situation. The Nurse Practice Act of the State is essential for guiding nursing practice, standards of clinical nursing practice ensure quality care, and personal values are important; however, the primary focus during a strike should be on the role of nurses as client advocates.
What action should the nurse take after a client produces the first of a series of sputum samples for cytology?
- A. Ensure the client remains NPO until all samples are collected
- B. Transport the sputum container to the laboratory in a biohazard bag
- C. Discard the initial sample and document the time it was obtained
- D. Document the time the client last ate or drank on the laboratory slip
Correct Answer: B
Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.
The healthcare provider is evaluating a client for potential dehydration. Which assessment finding is most indicative of fluid volume deficit?
- A. Moist mucous membranes
- B. Increased urine output
- C. Decreased skin turgor
- D. Elevated blood pressure
Correct Answer: C
Rationale: Corrected Rationale: Decreased skin turgor is a classic sign of dehydration. When someone is dehydrated, the skin loses its elasticity and becomes less turgid. This change is easily assessed by gently pinching and pulling up the skin on the back of the hand or forearm. If the skin remains elevated or tents rather than quickly returning to its normal position, it indicates dehydration. Moist mucous membranes (Choice A) are actually a sign of adequate hydration. Increased urine output (Choice B) can be a sign of dehydration, but decreased skin turgor is a more specific indicator. Elevated blood pressure (Choice D) is not typically associated with fluid volume deficit and may indicate other health issues.
A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left-side paralysis
Correct Answer: B
Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.