Nokea
During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?
- A. Record the findings and report the symptoms to the charge nurse
- B. Ask the family members to visit more often to stimulate the patient
- C. Motivate the client by offering favorite foods as a prize
- D. Withhold any medications that may cause side effects
Correct Answer: A
Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.
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An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?
- A. Notify the healthcare provider or charge nurse immediately
- B. Offer to reschedule the treatment for the following week
- C. Plan to monitor the client's vital signs every 30 minutes
- D. Reinforce the need for extra rest periods and plenty of sleep
Correct Answer: D
Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.
The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?
- A. Ask another nurse to return with the medication when the client has hung up the phone
- B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
- C. Return the medication to the client's drawer on the cart and document that the client refused the dose
- D. Leave the medication with the client and let him take it when he finishes the conversation
Correct Answer: B
Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.
An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?
- A. Plan to have the same nursing staff provide care for the client whenever possible
- B. Describe the activities available to residents and encourage him to choose the ones he prefers
- C. Encourage the client to remain on the unit for three weeks until he is oriented to his new surroundings
- D. Introduce the client to the nursing staff and other residents as soon as possible
Correct Answer: A
Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer's disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.
A client has a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the nurse reinforce about the action of this adjuvant pain modality?
- A. The discharge of electricity will distract the client's focus from the pain
- B. An infusion of medication in the spinal canal will block pain perception
- C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
- D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain
Correct Answer: D
Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus to the skin, which can help close the 'gates' in the nervous system to block pain signals from reaching the brain, thus reducing pain perception. Choice A is incorrect because TENS does not distract from pain but rather helps manage it. Choice B is incorrect as it describes a different pain management technique involving medication in the spinal canal. Choice C is incorrect because TENS acts peripherally on nerve conduction rather than dulling pain perception in the cerebral cortex.
The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time?
- A. Consultation with the case manager and hospital chaplain
- B. Visiting after procedures are done to avoid seeing the client in pain
- C. Participating in the client's care within his/her capabilities and desires
- D. Information about palliative and hospice care services
Correct Answer: D
Rationale: Providing information about palliative and hospice care services can help the spouse understand the options for managing the client's symptoms and improving the quality of life. This also provides support and guidance during a difficult time. Consulting with the case manager and hospital chaplain may be beneficial for emotional support but may not address the practical aspects of care. Visiting after procedures are done to avoid seeing the client in pain may not foster open communication and support. While participating in the client's care is important, providing information about palliative and hospice care services is the most helpful intervention in this scenario.