Pain tolerance in an elderly client with cancer should:
- A. Stay the same.
- B. Decrease.
- C. Increase.
- D. Cancer should have no effect on pain tolerance for an elderly client.
Correct Answer: B
Rationale: There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.
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What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and Bandaids™
Correct Answer: B
Rationale: Repositioning is the most effective way to prevent skin breakdown.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.
The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.
- A. Ask the client's permission to open containers and cut up meats on the food tray.
- B. Obtain special easy-to-hold, built-up silverware for the client to use when eating.
- C. Observe the client, but avoid providing assistance even if the client is frustrated.
- D. Help feed the client if the client is eating too slowly so food does not get too cold.
- E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
Correct Answer: A,B,E
Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
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