Nokea
The client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful?
- A. Position the client facing the nurse
- B. Enunciate directions very slowly
- C. Use gestures and body language
- D. Ask the client to point to needed objects
Correct Answer: D
Rationale: Having the client face the nurse will not aid the client in expressing his or her needs. The nurse’s slow enunciation of directions will not aid the client in expressing his or her needs. Using gestures and body language will not aid the client in expressing his or her needs. Asking the client to point to needed objects would be most helpful when the client is having difficulty communicating with the nurse.
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Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.
The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The assistant attempts to insert an oral airway.
- B. The assistant turns the client on the right side.
- C. The assistant has all the side rails padded and up.
- D. The assistant does not leave the client's bedside.
Correct Answer: A
Rationale: Inserting an oral airway during a seizure (A) risks injury and is contraindicated. Turning to the side (B), padding rails (C), and staying with the client (D) are appropriate.
Which client statement indicates a need for further teaching about meningitis precautions?
- A. I'll wear a mask when visitors come.'
- B. My family should wash their hands frequently.'
- C. I can share my water bottle with my spouse.'
- D. I'll stay in my room to avoid spreading germs.'
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.
The client has had recurrent episodes of low back pain. Which statement indicates that the client has incorporated positive lifestyle changes to decrease the incidence of future back problems?
- A. “I stoop and avoid bending and twisting when lifting objects.”
- B. “I can walk farther if I wear my old comfortable shoes.”
- C. “I can walk only on weekends but walk 5 miles each day.”
- D. “I sit for 2 to 3 hours with my legs elevated for pain control.”
Correct Answer: A
Rationale: Stooping and avoiding bending and twisting motions when lifting objects lessen the likelihood of injury. The client should wear supportive shoes. The client should include regular daily exercise as a program (not excessive walking over 2 days on the weekend). Clients should avoid prolonged sitting or standing.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.