Nokea
An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?
- A. Your husband is choosing to live in a happier time in his life.
- B. Redirect your husband to speak about current events when he begins regressing into the past.
- C. If he were my husband, I would call our minister to speak to him.
- D. Your husband is reflecting on his life. This is normal at his age.
Correct Answer: D
Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.
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The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- A. Roast beef sandwich, potato chips, pickle spear, iced tea
- B. Split pea soup, mashed potatoes, pudding, milk
- C. Tomato soup, cheese toast, Jello, coffee
- D. Hamburger, baked beans, fruit cup, iced tea
Correct Answer: B
Rationale: Soft foods like split pea soup, mashed potatoes, and pudding are easier to swallow for a client with a facial stroke, reducing the risk of aspiration.
A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:
- A. Tilt the head back and pinch the nostrils
- B. Apply a wrapped ice compress to the nose
- C. Pack the nose with soft, clean tissue
- D. Tilt the head forward and pinch the nostrils
Correct Answer: D
Rationale: Tilting the head forward and pinching the nostrils prevents blood from entering the airway and controls bleeding.
A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?
- A. The client complains of feeling tired and listless.
- B. The client has waxy, pale skin.
- C. The client exhibits loss of coordination and position sense.
- D. The client has a rapid pulse rate and a detectable heart murmur.
Correct Answer: C
Rationale: Loss of coordination and position sense are neurological symptoms due to vitamin B12 deficiency in pernicious anemia.
The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.