Nokea
Following a stroke, a client is found to have receptive aphasia. This finding is consistent with damage to:
- A. The frontal lobe
- B. The parietal lobe
- C. The temporal lobe
- D. The occipital lobe
Correct Answer: C
Rationale: Receptive aphasia, difficulty understanding language, is associated with damage to the temporal lobe, specifically Wernicke's area.
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The nurse is performing in-service education about the use of the defibrillator.
Which of the following statements, if made by the nurse, is MOST important?
- A. Do not touch the bed when using the defibrillator.
- B. Check the defibrillator every 24 hours.
- C. Do not leave the defibrillator plugged in.
- D. Do not place the paddles over the electrodes.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-is a priority to prevent accidental countershock (2) equipment should be checked every eight hours (3) equipment should remain plugged in at all times (4) is not a priority; while this should not occur, it can be safely done
The nurse is preparing to change the dressing of a client with a venous access device. Because it is the first time the nurse has performed the skill, he reads the unit policy manual and asks another nurse how to best perform the dressing change. The skill level of the nurse at this time is best described as:
- A. Novice
- B. Proficient
- C. Competent
- D. Expert
Correct Answer: A
Rationale: A nurse performing a skill for the first time, relying on guidelines and assistance, is a novice. Higher levels require experience and independence.
The nurse is teaching a client with asthma about the use of a metered-dose inhaler. Which of the following instructions should the nurse include?
- A. Inhale quickly while pressing the canister.
- B. Hold the breath for 2 seconds after inhaling.
- C. Shake the inhaler well before use.
- D. Use the inhaler every 2 hours routinely.
Correct Answer: C
Rationale: Shaking the inhaler ensures proper medication dispersion. Options A, B, and D are incorrect techniques or schedules.
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
- A. Report the family to family protective services.
- B. Congratulate the family on solving the problem.
- C. Help the family think of ways to make the environment safer for the client.
- D. Tell the family that they are not allowed to restrain the client with a leather belt.
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
- A. White blood cell count of 12,000/mm^3.
- B. Temperature of 100.4°F (38°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.