Nokea
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
- A. Chronic fatigue syndrome
- B. Normal aging
- C. Sundowning
- D. Delusions
Correct Answer: C
Rationale: Sundowning is a common phenomenon in dementia where confusion worsens in the late afternoon and evening.
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The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
- A. Provide the client with a urinal
- B. Prep the area by shaving the abdomen
- C. Encourage the client to drink extra fluids
- D. Request an ultrasound of the abdomen
Correct Answer: A
Rationale: Providing a urinal allows the client to empty their bladder, reducing the risk of bladder puncture during paracentesis.
The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse's best response at this time is to:
- A. Attempt to perform the procedure
- B. Refuse to perform the procedure and give a reason for the refusal
- C. Request to observe a similar procedure and then attempt to complete the procedure
- D. Agree to perform the procedure if the client is willing
Correct Answer: B
Rationale: Refusing and explaining the lack of qualification ensures patient safety and adheres to ethical standards.
The nurse is conducting an aphasia assessment of a client who has suffered a stroke. Which of the following observations should the nurse include in the assessment? Select all that apply.
- A. Spontaneous speech.
- B. Comprehension of the spoken and written word.
- C. Ability to name objects.
- D. Ability to describe objects.
- E. Ability to write.
- F. Ability to recall four named items after five minutes.
Correct Answer: A,B,C,D,E
Rationale: Aphasia assessment post-stroke includes evaluating spontaneous speech (A), comprehension (B), naming objects (C), describing objects (D), and writing (E). Memory recall (F) is not specific to aphasia.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.
The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?
- A. I should inhale through my mouth.'
- B. I should tighten my abdominal muscles with inhalation.'
- C. I should contract my abdominal muscles with exhalation.'
- D. I should make inhalation twice as long as exhalation.'
Correct Answer: C
Rationale: Pursed-lip breathing involves inhaling through the nose and exhaling slowly through pursed lips, which may involve contracting abdominal muscles to assist with exhalation, prolonging exhalation to reduce air trapping in COPD.