Nokea
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
- A. Aphasia
- B. Apraxia
- C. Dysarthria
- D. Dysphagia
Correct Answer: A
Rationale: Aphasia (A) is a language disorder causing difficulty with word choice or expression, common in stroke affecting language centers. The client’s ability to follow commands but use incorrect words suggests expressive aphasia. Apraxia (B) affects motor planning, dysarthria (C) impairs speech articulation, and dysphagia (D) involves swallowing difficulties, none of which match the described deficit.
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Which of these clients would be appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with multiple lacerations and requires complex dressings
- B. An elderly client with cystitis and an indwelling urethral catheter
- C. A confused client whose family complains about the nursing care 2 days after surgery
- D. A client admitted for possible transient ischemic attack with unstable neurological signs
Correct Answer: B
Rationale: This is a stable client, with predictable outcome and care and minimal risk for complications.
The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences
- A. Ear pain
- B. Foul-smelling breath
- C. Frequent swallowing
- D. Low-grade fever
Correct Answer: C
Rationale: Frequent swallowing (C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (A), bad breath (B), and low-grade fever (D) are common and less urgent.
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain?
- A. Ask the parent who is present if the child appears to be in pain.
- B. Observe the child's behavior carefully.
- C. Ask the child where it hurts and how badly it hurts.
- D. Have the child look at pictures of faces and select the one that best describes how he feels right now.
Correct Answer: B
Rationale: A 1-year-old cannot verbalize pain; observing behavior (e.g., crying, guarding) is the most reliable pain assessment method.
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.