For a client who has sustained recent blindness, which task(s) would be appropriate to delegate to the nursing assistant? (Choose all that apply.)
- A. Listen to the client express grief or loss.
- B. Assist client to ambulate in hall.
- C. Orient client to surroundings.
- D. Encourage independence.
Correct Answer: B
Rationale: Assisting with mobility is within the scope of practice for nursing assistants and ensures safety for the client.
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18. Melatonin’s use is based on scientific evidence. The patient with which problem would benefit from melatonin?
- A. Sleep problems
- B. Mild depression
- C. High cholesterol
- D. Benign prostatic hyperplasia
Correct Answer: A
Rationale: Melatonin is scientifically supported for addressing sleep problems (option A), such as insomnia or jet lag.
Cognitive changes include memory problems, confusion, and disorientation. These changes:
- A. Occur in 75% of patients over age 65
- B. Are not a normal part of aging
- C. Are due to enhanced cerebral blood flow
- D. Cause senile plaques and neurofibrillary tangles
Correct Answer: B
Rationale: Cognitive decline is not a normal part of aging; it may indicate underlying conditions such as dementia or Alzheimer's disease. Normal aging involves mild forgetfulness but not significant impairment.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
Which statement by a patient with diabetes indicates an understanding of the medication insulin glargine injection (Lantus)?
- A. Lantus causes weight loss.
- B. Lantus is used only at night.
- C. The duration of Lantus is six hours.
- D. There is no peak time for Lantus.
Correct Answer: D
Rationale: Lantus is a long-acting insulin with no distinct peak action.