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An older adult is seen in clinic. During the assessment process, all of the following are expressed or noted. Which is of most immediate concern to the nurse?
- A. The client's daughter says that the client has become increasingly forgetful.
- B. The client has a productive cough.
- C. The client ambulates slowly.
- D. The client says, 'My arms aren't long enough for me to read the paper.'
Correct Answer: B
Rationale: A productive cough suggests a respiratory infection, potentially serious in an older adult, requiring immediate evaluation. Forgetfulness, slow ambulation, or presbyopia are less urgent.
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The nurse is planning care for a client who has a hearing impairment. Which action will likely help the most with communication?
- A. Repeat everything twice.
- B. Speak loudly.
- C. Speak slowly and clearly.
- D. Use gestures.
Correct Answer: C
Rationale: Speaking slowly and clearly enhances comprehension for hearing-impaired clients. Repeating, shouting, or gestures may confuse or overwhelm.
An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?
- A. The diseased liver is not able to convert bilirubin into bile, so bilirubin pigments stay in the bloodstream and cause the skin and sclera to turn yellow.
- B. The virus that causes hepatitis A leaves a yellow pigment in the bloodstream.
- C. The affected liver cells produce more bilirubin than usual, causing the skin to turn yellow.
- D. The body is trying to get rid of fecal waste products through the skin.
Correct Answer: A
Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.
The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior?
- A. Muscle rigidity and shuffling gait
- B. Nihilistic delusions
- C. Tangential speech
- D. Waxy flexibility
Correct Answer: A
Rationale: Benztropine is an anticholinergic used to treat extrapyramidal symptoms (EPS), such as muscle rigidity and shuffling gait, which are side effects of antipsychotics like haloperidol.
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of time-out
- D. Explain that the child needs extra attention
Correct Answer: B
Rationale: Explain that this behavior is expected. Fear of strangers is normal in toddlers and extends into the preschool period.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.