Nokea
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
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While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset
At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
The nurse teaches a group of boy scouts how to prevent Lyme disease. Which of the following statements, if made by one of the boy scouts to the nurse, would indicate that further teaching is necessary?
- A. When I go on a long hike, I should check any exposed skin for insects every four hours.
- B. When I hike in the woods, I should wear long pants, socks, and a long-sleeved shirt.
- C. I should remove any ticks by crushing them firmly against the skin.
- D. I should reapply insect repellant every couple of hours when hiking.
Correct Answer: C
Rationale: should not be crushed, remove tick with tweezers or fingers and flush down toilet; burning a tick could spread infection
A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?
- A. Report an increase in blurred vision.
- B. Eat soft, warm foods.
- C. Change positions slowly.
- D. Chew food on the affected side.
Correct Answer: B
Rationale: intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
The nurse is teaching a client with newly diagnosed diabetes mellitus how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia are experienced?
- A. Eat a candy bar.
- B. Drink ½-cup fruit juice followed by a protein snack.
- C. Inject 10 units of Humulin R.
- D. Inject glucagon.
Correct Answer: B
Rationale: will correct hypoglycemia and stabilize blood sugar