Nokea
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
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The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation of stimuli
- D. Emotional lability
Correct Answer: A
Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.
A client has sustained second- and third-degree burns over her entire left arm and posterior trunk. Using the Rule of Nines, which percentage of the client's body is burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: C
Rationale: Per the Rule of Nines, one arm is 9% and the posterior trunk is 18%, totaling 27% body surface area burned.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.